March 27, 2006

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MMA Testifies on Self-Insurance Option for Dirigo Choice
Governor John Baldacci has proposed that the Dirigo Health Agency Board of Directors be given the authority to fund healthcare for DirigoChoice enrollees through a self-funded plan, administered by a third party administrator. The authority would be used as a potential alternative to Anthem, should Anthem not negotiate an acceptable contract to continue the program after December 31, 2006.
During a five hour hearing on March 21, MMA EVP Gordon Smith presented testimony to the Joint Standing Committee on Insurance & Financial Affairs on an amendment to L.D. 1845 which would allow the Dirigo Health Agency Board of Directors to establish a self-insurance vehicle for the DirigoChoice product as a potential alternative to the current partnership with Anthem Blue Cross Blue Shield of Maine.

While testifying in the neither for/nor against category, Mr. Smith urged support for language to be added to the amendment indicating that the plan would be required to pay providers at rates comparable to those paid by commercial insurance companies.  He also noted the need for better language regarding solvency standards, stop-loss insurance and further noted that the self-insurance alternative was just an option, and a necessary one given that otherwise Anthem could hold the state hostage as the only potential bidder to offer the DirigoChoice product.

In response to a question about continuing concerns about Mainecare and MECMS, Smith acknowledged concerns from physicians as to whether the state could be trusted to competently run a state-sponsored self-insurance fund.  "We would expect the fund to be administered by a licensed third party administrator," Smith said.  "If the option were the state creating its own insurance company, it is unlikely that we could have supported it as the track record at MaineCare is so poor.  But the state needs some alternative if no commercial insurer is willing to partner with the state to offer the product.  That being the case,  establishing a self-insurance pool is a reasonable choice, so long as appropriate oversight is required and solvency standards applied."

The Committee will hold a work session on the amendment Tuesday, March 28th at 1:00 p.m.

Faculty Announced for June 21 Practice Education Seminar in Bangor
The following presenters have been announced for the June 21 Practice Education Seminar to be held at Spectacular Event Center in Bangor.   Erik Steele, D.O., Chief Medical Officer for Eastern Maine Medical Center and a weekly columnist for the Bangor Daily News will present the keynote talk at 8:30am.

  • J. Michael Hall, Deputy Commissioner, Maine Department of Health and Human Services
  • Laureen Biczak, D.O., Medical Director, Office of MaineCare Services
  • Michael Duddy, Esq.
  • William Stiles, Esq.
  • Kenneth Lehman, Esq.
  • John Gleason, Esq.
  • Jan Wnek, M.D.
  • Lisa Letourneau, M.D., MPH
  • Maureen Kenney, Manager, Heatlhcare Strategy, Bath Iron Works
  • Suanne Singer, Maine Health Information Center
  • Chris Baumgartner, Office of Substance Abuse
  • Vaughn Clark, The Thomas Agency
  • Tarren Bragdon
  • Andrew MacLean, Esq.
  • Gordon Smith, Esq.
  • Michel LaFond, Esq.
  • Jay McCloskey, Esq.
  • Jana Purrell, CPC
  • Laurie Desjardins, CPC, CCS-P
  • Randal Manning

Other presenters may be added.  In particular, we are awaiting confirmation from CMS regarding an update on Medicare, Pay 4 Performance, etc.   We may also add an additional breakout session on Medicare Part D appeals.

Watch for registration materials included with your March/April 2006 issue of Maine Medicine or call 622-3374 to reserve a space for the day long program, running from 8:30a.m. to 4:00p.m.  This Fifteenth Annual Practice Education Seminar is co-sponsored this year by The Maine Health Alliance.

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MaineCare MECMS Update
The Association continues to work with a number of members and the Office of MaineCare Services (OMS) regarding the difficult transition to the new claims management system (MECMS).  As readers painfully know, this problem is now going into its 15th month.  While week to week processing continues to gradually improve, with nearly 90% of new claims being processed by the system (about 20% of those are denied), many problems remain.  OMC staff are currently expediting the processing of paper claims for Part B cross-over payments, as electronic payment on these claims is not expected until September.

Some MMA members have been asked to begin the recoupment process of interim payments.  Members should be aware that they will only be required to begin the recoupment process if their account with MaineCare is now properly settled.  In other words, if your claims are now processing on a timely manner, so that you have, in fact, been paid twice for the same service, you will be asked to being the repayment process.   If, on the other hand, you are still owed for suspended claims, the primary care case management fee, or the Part-B crossovers, you may ask for more time for the recoupment.  Most physician practices are in a later phase of interim payment recovery and will not be even hearing from the state until after the completion of the state's fiscal year, which is June 30, 2006.

It is helpful for MMA to hear from members or their staffs regarding the claims payment issue.  Please keep us up to date on problems you are having by e-mailing Gordon Smith at

The Governor's Provider Advisory Committee, assigned the task of advising MaineCare with respect to the problem, will meet again this coming Thursday, March 30. [return to top]

Important Medicare Part D Appeals Notice for Physicians
To All Maine Medical Association Members:

Your assistance is needed to get some very important information out to your members regarding Medicare Prescription Drug Coverage (Part D). As you know, many people with Medicare have enrolled in Medicare Prescription Drug Plans and many others who are dually eligible for both MaineCare and Medicare, as well as members of the Low-Cost Drugs for the Elderly and Disabled Program (DEL) have been autoenrolled into Plans. The State of Maine has temporarily
continued to cover people in the MaineCare and DEL programs, and the federal government has required Part D plans to provide transitional drug benefits through the end of March: as a result, patients and their physicians may not have felt yet the full impact of this new drug program. When these temporary benefits end, prior authorizations or exceptions will be needed in many cases in order to get medications under Medicare Part D.

There is an opportunity right now, while these temporary benefits are still in place, to avoid an overwhelming number of calls from patients by taking the time to identify problems and assist your patients with coverage issues.

Information about Medicare Part D Plan formularies, and links to the forms required to process Part D coverage determinations and exception requests, may be found on Legal Services for the Elderly’s website at


If a patient tells you that a drug has been denied or is too costly, and you don’t know the reason, request a Coverage Determination from the Plan.  To find the needed forms and contact information for the Plans to make this request, go to the link above.  The Plan is required to respond within 72 hours. 


If it is medically appropriate, you may at any time suggest an alternate drug on a patient’s Plan formulary.  To find the formulary for a Plan, go to the link above (or, if you use Epocrates, all the Medicare Part D formularies are available for uploading).

Requesting an Exception:  If a drug has been denied or is too costly, and you believe your patient requires that particular drug, request an Exception from the Plan so that the patient can get that particular drug (or get it with a reduced co-pay).  To find the needed forms and contact information to request an Exception, go to the link above.  The Plan is required to respond within 72 hours. 


If your patient’s health will suffer without the prescribed drug, be sure to request an EXPEDITED Determination and/or Exception, and then the Plan must respond within 24 hours.  If the Plan is not responding to your requests in a timely manner, contact Legal Services for the Elderly at 1-877-774-7772 for assistance.


If your patient has been denied coverage of a drug or a drug is too costly and your patient requires that particular drug, Legal Services for the Elderly may be able to assist you and your patient in appealing the denial.  Common reasons for denial that might lead to appeal include:

  • The Plan takes the position that the prescribed drug is not medically necessary.
  •  The drug is not on the Plan’s formulary.
  • The drug required prior authorization and it was denied or not obtained.
  • The Plan has stopped covering the drug.
  • The prescribed dosage is not covered by the Plan.
  • The prescribed form (liquid/pill/injectible) or type (generic/brand name) of drug is not covered by the Plan.
  • The Plan is requiring that other medications be tried first.
  • The patient/Member is unable to pay the required cost-sharing.

Call Legal Services for the Elderly’s Medicare Part D Unit at 1-877-774-7772 for assistance with appeals.  LSE accepts calls Monday through Friday (except holidays) from 9:00 a.m. to 12:00 p.m., and 1:00 p.m. to 4:00 p.m. 


Jude Walsh                Jaye Martin    
Special Assistant       Executive Director     
Governor's Office of Health Policy & Finance
Legal Services for the Elderly [return to top]

Study Cites Drop in Percentage of Physicians Providing Charity Care
On March 23, 2006, the Center for Studying Health System Change (HSC) released a study entitled, A Growing Hole in the Safety Net:  Physician Charity Care Declines Again.  The study concludes that while the number of uninsured Americans is growing, the percentage of physicians providing charity care is declining. 

Key findings of the study include:

  • 68% of physicians were providing charity care in 2004 and 2005, compared with 76% in 1996 and 1997;
  • the decline was consistent across all specialties, income levels, and geographic regions, including rural and urban areas;
  • physicians in solo or small practices and those who are sole or part owners of the practice provide the most charity care;
  • health plan efforts to reduce cost shifting, time pressure for physicians, and movement towards larger physician practices with less physician ownership are cited as reasons for the decrease.

You can find the report on the web at:

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DHHS Secretary Leavitt Reports Positive Numbers in Medicare Part D Enrollment
On March 23, 2006, U.S. Department of Health & Human Services Secretary Michael O. Leavitt announced that the number of Medicare beneficiaries receiving drug coverage through the Medicare Part D benefit has risen to approximately 27 million individuals with 1.9 million new beneficiaries enrolling since mid-February.  7.2 million of these beneficiaries have enrolled themselves, navigating a process that has been called too complex.  The Bush Administration has set a goal of 28 to 30 million enrollees in the first year of the new program. 

More information on the Medicare Part D enrollment is available on the CMS web site at:

Local information about the Part D benefit and the appeals process is available on the Legal Services for the Elderly web site,

The New York Times of Sunday, March 26, 2006 includes a positive article on Part D enrollment by Robert Pear entitled For Some Who Solve Puzzle, Medicare Drug Plan Pays Off.  The article may be found on the web at:  You may have to register to access the article. [return to top]

Representatives of MHA Council on Quality to Meet with MMA Committee
On Tuesday, April 11, at 4:00pm, the MMA Committee on Peer Review and Quality Improvement will meet and hear from Deborah C.Johnson, CEO of Eastern Maine Medical Center and Chair of the MHA Council on Quality and Sandra Parker, J.D., MHA staff  to the Council.  The purpose of the meeting is to discuss ways in which the two committees can work together toward the common goal of improving the quality of medical care in Maine.  The two bodies have some over-lapping membership and it has been a goal for some time now to begin a process of collaboration.  The meeting will be held at the Frank O. Stred Building in Manchester, which houses the MMA offices.

Both the Maine Hospital Association and the Maine Medical Association have noted quality improvement as strategic imperative now and in the years ahead.

Krishna Bhatta, M.D. chairs the MMA Committee.  William Strassberg M.D. is the VIce-Chair. [return to top]

Maine Chapter, AAP Presents Pediatric Potpourri, May 6-7, 2006 at Samoset Resort
Maine Chapter, American Academy of Pediatrics Spring Educational Conference

Pediatric Potpourri
May 6-7, 2006
Samoset Resort, Rockland, ME

Featured Speaker: Dr. Lewis First, Chairman of the Department of Pediatrics at the University of Vermont College of Medicine

Topics include: Pediatric Hot Topics, Pediatric Check-Up, Newborn Screening, Asthma, Atopic Dermatitis, Calcium Intake Guidelines, Pediatric Consent, Immunizations Review, as well as sessions on Coding and EMR.

Registration information is available online at or contact the Chapter Executive Director, Aubrie Entwood, at 685-9358 or
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Dr. Martin Merry to Address Maine Quality Forum Advisory Council, April 14 in Augusta
The Maine Quality Forum Advisory Council invites you to join them for a presentation by Dr. Martin Merry, a clinician, educator, and expert in helping good medical organizations become exceptional ones. Dr. Merry will be sharing his vision for creating an ultra-safe health care system.
Dr. Merry’s extensive experience in analyzing and explaining the challenges of improving health care quality ground his belief that we need to develop an integrated system of care with a goal of
zero defects in health care delivery. Drawing from his experience in New England and the entire U.S., Dr. Merry will discuss the context for quality and safety improvements in Maine, energizing and encouraging our quality improvement efforts as he has energized many in the United States.

Dr. Merry’s presentation will be 10:30am-12:00pm on Friday, April 14 at 211 Water Street,  Augusta, in the Dirigo Health Agency Building. [return to top]

Gubernatorial Candidates Weigh in on Dirigo
Republican Gubernatorial Hopeful Chandler Woodcock is the latest candidate to speak out on Dirigo Health and to offer an alternative.  At an event last Friday, Woodcock, who is from Farmington, talked about his vision for reforming Maine's health care system.

Generally speaking, State Senator Woodcock made the following points:

  • He was critical of the state's failure to pay its MaineCare bills on time
  • He supported medical liability reform, as necessary to attract and retain physicians in Maine
  • He advocated for making the health insurance market more competitive by decreasing regulations and eliminating state mandates (both are traditional Republican views)
  • He opposed the continuing use of the so-called Savings Offset Payment to fund Dirigo
  • He supported wellness programs
  • He advocated for MaineCare reform which would narrow eligibility but provide better benefits for those who are eligible
  • He advocated for a stronger statewide public health system

Neither the Maine Medical Association or the Maine Physician Action Fund endorse candidates in the gubernatorial election.  Rather, each physician is encouraged to participate in the campaign of their choice.  You may learn more about the Republican candidates online at;; and

Governor Baldacci's campaign website is at [return to top]

The Coding Center's Coding Tip of the Week
National Heritage Insurance Company (NHIC) has the following guidelines for using the Admit/Discharge same day (including Observation services)--For a physician to appropriately report CPT codes 99234 through 99236

  • The patient must be an inpatient or an observation care patient for a minimum of 8 hours on the same calendar date.
  • When the patient is admitted to observation status for less than 8 hours on the same date, the physician would use CPT codes 99218 through 99220 and no discharge code must be reported.
  • When patients are admitted for observation care and then discharged on a different calendar date, the physician uses CPT codes 99218 through 99220 and CPT observation discharge code 99217.
  • When patients are admitted to inpatient hospital care and then discharged on a different calendar date, the physician uses CPT codes 99221 through 99233
    and CPT hospital discharge  codes 99238 or 99239.
  • For an inpatient admission with discharge less than 8 hours later on the same calendar date, CPT codes 99221 through 99223,are used for the admission service, and the hospital discharge service is not be billed.
  • The physician should meet the documentation requirements for both admission to and discharge from inpatient or observation care to bill CPT codes 99234, 99235, or 99236. The length of time for observation care or treatment status must also be documented.

Questions? Call the Coding Center: 1-888-889-6597 [return to top]

OSA Develops Real-time Portal to Access Prescription Monitoring Program Data
The Office of Substance Abuse (OSA) has developed a real-time portal to access prescription monitoring program data.  Data is currently collected bi-monthly from all pharmacies licensed with the state.  This data is collected by GHS Data Management who provides manually built reports from their office.

To register for the PMP program please go to and download the paper form for registration and mail or fax it in.  Or you can click the PMP Service Page link on this page to register online.

Once registered & certified by OSA, (certification is sent by fax or mail along with a User Name & Password) your account is activated to request paper reports from GHS Data Management (using the paper form you can download at the site above) or you can logon to the PMP Service Page again and request your paper report online.  GHS will build manual reports from mailed, faxed, and electronic requests (through their portal) and return the report within 24 hours of the request being received (barring weekends and holidays).

If you would rather build your own reports online (so you have the report more quickly) register through the GHS Portal & wait for approval.  Once you have received your approval from GHS use your User Name, Password, & Electronic-signature for the real-time portal at  The Electronic Signature will be sent to you by GHS when you register or if you have already registered, you should have received the signature in a letter from OSA and your account is already activated on the new portal.  This portal allows registered prescribers (for patients under their care) & dispensers (for customers seeking to have a prescription filled) to enter a first name, last name, and date of birth to generate (within 5 to 10 minutes) a report of all issued prescription drugs (Schedule II, III, and IV).  To provide the appropriate security for such easy access all account passwords will be changed every 90 days (the system will prompt the user to change it).

To learn how to use the Prescription Data Portal download the manual from the Help link once you have logged into the portal.

Once registered, a prescriber or dispenser can make requests for manually built reports or build their own as often as they like.

For more information, contact:
Chris Baumgartner, Program Coordinator
Phone: (207) 287-3363
Fax:     (207) 287-4334
Email: [return to top]

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