April 3, 2006

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Governor Baldacci Releases New State Health Plan
The Baldacci Administration's first biennial state health plan reflects more than a year of work by the Advisory Council on Health System Development and focuses on prevention and controlling chronic disease.

Today, Governor Baldacci announced the release of Roadmap to Better Health:  Maine's State Health Plan 2006/2007

The Governor's press release highlights the following points in the Plan:

  • Creation of a more organized system to deliver prevention and public health building on strong bonds with community coalitions operating across the state, neighborhoods and towns.
  • Seeks innovations in telemedicine to assure our most rural citizens have access to a full array of health care choices and that the system of care reaches every part of Maine and strengthens rural health capacity.  A rural health workgroup will be appointed to assure this goal is met.
  • Seeks a culture of health in the state asking each citizen to sign a "Be Fit for Maine" contract taking appropriate steps to move closer to better health.
  • Establishes a "Wellness Star" program through the Maine Quality Forum to recognize business innovation in keeping employees healthy and assure that best practices are shared with other businesses.
  • The Maine Quality Forum will launch a new initiative statewide to improve the treatment of heart attacks.
  • Improve services to people with mental illness by better integrating primary care and behavioral health services and by establishing policies for depression screening to assure early detection and treatment.
  • Creation of a Health Policy Leadership Forum representing business, insurers, providers, consumers, and government to assure an ongoing dialogue about how best to make Maine the healthiest state and achieve universal access.

You can read the entire press release on the web at:  http://www.maine.gov/governor/baldacci/healthpolicy/news/4_3_06.htm.  The press release includes a link to the PDF version of the Plan which is 146 pages long.

Governor Baldacci Posts Brenda Harvey for DHHS Commissioner
On Friday, March 31, 2006, Governor Baldacci posted Brenda Harvey for the position of Commissioner of the Department of Health & Human Services.  Ms. Harvey has been Acting Commissioner of the Department since the departure of Jack Nicholas.  You can read the Governor's press release on the announcement on the web at:  http://www.maine.gov/tools/whatsnew/index.php?topic=Portal+News&id=15036&v=article-2004. [return to top]

Supplemental Budget Passes Easily; Becomes Effective 3/29/06
The unanimous Appropriations Committee report on the SFY 2006-2007 supplemental budget (L.D. 1968) was enacted in both the House and Senate and signed into law by the Governor as an emergency measure on Wednesday, March 29, 2006.

For detailed information about the supplemental budget, see the Budget Overview prepared by the Office of Fiscal & Program Review on the web at:  http://www.maine.gov/legis/ofpr/LD%201968/LD%201968%20CA.htm.

Some highlights of the supplemental budget are:

  • $2 M for AMHI Consent Decree compliance in FY 2007 (Part A - DHHS/BDS)
  • $1 M for reimbursement of interest costs incurred by providers in MECMS transition (Part A - DHHS/Medical Care - Payments to Providers)
  • Medicare Part D transition assistance (Part AAA)
  • DHHS report on recovery of MECMS interim payments (Part DDD)
  • Report on hospital settlements (Part EEE)
  • Restoration of Fund for a Healthy Maine cuts in FY 2006 (Part FFF)
  • Hospital settlements (Part HHH)
  • Managed behavioral health care services system (Part ZZZ)
  • Content of L.D. 151, An Act to Improve the Delivery of Maine's Mental Health Services (involuntary outpatient treatment) (Part BBBB)
  • MaineCare drug formulary (Part DDDD)

You can view the entire text of L.D. 1968 (P.L. 2005, Chapter 519) on the web at:  http://janus.state.me.us/legis/LawMakerWeb/externalsiteframe.asp?ID=280020163&LD=1968&Type=1&SessionID=6. [return to top]

Insurance Committee Finalizes Self-Insurance Option for Dirigo
During a work session on Friday, March 31, 2006, the Insurance & Financial Services Committee split along party lines on L.D. 1845, An Act to Increase Access to Health Insurance Products.  The committee amendment supported by majority Democrats will amend the governance of the Dirigo Health Agency and will establish standards by which the Agency could establish the Dirigo Health Self-Administered Plan.  The 7 Democratic members of the committee were present and voting in favor of this proposal.  Five of 6 Republican members of the committee were present and voted in favor of a minority report that would propose substantial changes to the entire Dirigo program, including the elimination of the "savings offset payment" (SOP) as a funding mechanism.

The MMA and MHA were particularly concerned that a self-insured approach to Dirigo would continue the principle in the original Dirigo law that providers would be paid at market rates of reimbursement, not MaineCare rates.  Today, the MMA offered the following alternative language on the payment issues and it was incorporated in the majority report.

14. Provider reimbursement.   In any contract with a third-party administrator, carrier or other organization to administer and provide health coverage to plan enrollees, the Dirigo Self-administered Plan shall ensure that:


A. Providers contracting to provide health coverage to plan enrollees are reimbursed at a rate comparable to the current market reimbursement rates among commercial carriers in the state; and


B. Providers contracting to provide health coverage to plan enrollees are paid in a timely manner in accordance with the same requirements that would be required under state law for health insurance carriers pursuant to Title 24-A, section 2436. ; and


C. In the event the Dirigo Self-administered Plan fails to pay for health care services as set forth in the contract, providers are governed by the same standards required pursuant to Title 24-A, section 4204, sub-section 6. This section does not prohibit a provider from collecting or attempting to collect from a plan enrollee any amount for services not normally payable to the agency, including any applicable copayments and deductibles.

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ALERT: Without Waiver, Practices Must Bill Health Claims Electronically
Because the MMA has heard that a number of physician practices still are unaware of an electronic billing requirement enacted as part of the Dirigo health plan legislation in 2003 and fully implemented through a Bureau of Insurance rule that became effective in September 2005.  These laws require all health care practitioners to submit claims electronically after October 16, 2005 while permitting practitioners to apply for a "hardship" exemption to the requirement until January 30, 2006, an extension of the original December 16, 2005 deadline. 

ALTHOUGH THE DEADLINE FOR SEEKING THE HARDSHIP EXEMPTION HAS PASSED, IF YOU DO NOT BELIEVE YOU REASONABLY CAN COMPLY WITH THE REQUIREMENT, YOU SHOULD APPLY FOR THE EXEMPTION IMMEDIATELY.  If the Bureau denies the application as not timely, you should appeal and state as "good cause," that you were not aware of the requirement or the possibility of an exemption until this notice.



            Some time prior to October 16, 2003, CMS stated that after that date all health care practitioners billing the Medicare program would have to do so electronically.  The federal requirement includes an exemption for practices with fewer than 10 FTE employees.  As part of its cost containment provisions, Governor Baldacci’s Dirigo health legislation incorporated a stricter version of this federal requirement.  P.L. 2003, Chapter 469, Part D, 24 M.R.S.A. §2985.  It included the exemption for practices with fewer than 10 FTE employees between October 16, 2003 and October 16, 2005 and then provided for a hardship exemption from the requirement after that date.  The legislation directed the Superintendent of Insurance to adopt rules governing the standards and process for obtaining a hardship exemption.  Bureau of Insurance Rule Chapter 825, Procedures and Standards for Obtaining a Hardship Exemption from Submitting Electronic Health Claims.

            During the Dirigo legislative debate, the Baldacci Administration placed great emphasis on pushing the adoption of health care information technology as a means of containing costs and improving efficiency in our health care system.  The hardship exemption was one of a handful of changes the MMA succeeded in negotiating on behalf of the physician community.

            You may find these laws on the web as follows:


o       P.L. 2003, Chapter 469, Part D:  http://janus.state.me.us/legis/ros/lom/LOM121st/10Pub451-500/Pub451-500-112.htm#P8275_918195.  See Sec. D-2.

o       BOI Rule Chapter 825:  http://www.maine.gov/sos/cec/rules/02/031/031c825.doc.


The Bureau of Insurance has a FAQ document on the electronic billing requirement on its web site at:  http://www.state.me.us/pfr/ins/Rule825_faq.htm.


You may submit your hardship exemption request in letter format or using the form on the Bureau’s web site to:  Joanne Rawlings-Sekunda, Bureau of Insurance, State House Station 34, Augusta, Maine 04333-0034.  You may contact Joanne at 624-8472 or by email at Joanne.Rawlings-Sekunda@maine.gov.  [return to top]

CMS Invitation to Partcipate in the Physician Voluntary Reporting Program
Dear Doctor:

Why should you participate in Medicare’s Physician Voluntary Reporting Program (PVRP)?

The PVRP is a new program that represents the first step towards gathering information on the use of physician quality measures.  Physicians who choose to participate will help capture data about the quality of care provided to Medicare beneficiaries in order to identify the most effective ways to use the quality measures in routine practice to improve quality of care.  The program is starting with 16 quality measures that were developed by physicians working with consensus organizations such as the Ambulatory Quality Alliance, the National Quality Forum, and the AMA Physician Consortium:  seven are primary care measures, two are for emergency physicians, two are for nephrologists, and five are for surgeons

Here’s why you should participate in PVRP now:

First, to assess your performance.  Based upon experience with hospital quality reporting, those who participate early benefit from learning about their performance prior to having payments attached to such reporting program.  The Physician Voluntary Reporting Program will provide information that will allow you to understand your performance compared to other physicians through confidential reports.

Second, as Congress contemplates revising the SGR (the formula that determines the physician fee schedule update)  there is interest in incorporating pay for reporting programs in such a revision.

Third, to make reporting as straightforward as possible, the PVRP uses G codes (and when they are available, CPT II codes) on the claim form to pass data to CMS.  Participation will give you the opportunity to ensure that your claims processor and office software can support this process.

Finally, your participation in PVRP now will help equip you with the experience to give CMS feedback on what works and what doesn’t in the new system.

Here’s how you can get started with PVRP:

Register to participate in the PVRP.  It should take no more than five minutes of your time, simply visit the website at www.qualitynet.org/pvrpintent.

Simple one-page worksheets developed specifically for doctors in your specialty are available under the Downloads section of PVRP Overview.  Have your office staff attach this worksheet to your internal service tracking forms (superbills) or patient chart, then check the appropriate box during the patient encounter.  This worksheet will help your office track PVRP services for reporting on your Medicare claims.
Get further information about the program online here: http://new.cms.hhs.gov/PVRP/01_Overview.asp

CMS is here to help!  Please don’t hesitate to contact us with any questions, issues, or concerns. Call us at 202-236-3338, or email us at PRIT@cms.hhs.gov
Attachments: Specialty Specific Work Sheet, MLN article:    http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4183.pdf  till April 4, 06 then  http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5036.pdf. [return to top]

REMINDER: Half-Day Program on HIPAA Compliance at MMA on 4/14/06
As part of our First Fridays seminar series, the MMA will present a yearly update on the HIPAA Privacy and Security Rules at the MMA office in Manchester on the morning of Friday, April 14, 2006.  Whether you have new staff or simply want to accomplish some of your annual HIPAA training, this program is for you!  You can register on the MMA web site, www.mainemed.com (under Seminars/First Fridays), or by contacting Gail Begin at gbegin@mainemed.com.


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The Coding Center's Coding Tip of the Week
ICD-9 reporting requirements--Medicare has recently clarified the reporting of diagnosis (ICD-9) codes on the claim form.  A provider can enter up to 4 codes in priority order (primary, secondary condition, etc) in item 21.  Providers must assign an ICD-9-CM code that provides the highest degree of accuracy and completeness.  The highest degree of specificity refers to reporting the most precise ICD-9- CM code that most fully explains the symptom or diagnosis—either a 3, or 4, or 5 digit code.  The level of specificity means that if a 3 digit code has a 4-digit code that further describes it, then the 3-digit code cannot be reported.  Make sure that the diagnosis on the claim is valid at the time the procedure is performed.  Reminder, ICD-9 codes become effective October 1 each year for all payors (with updates in April).

On item 24E, enter the diagnosis code reference number (1 or 2 or 3 or 4) from item 21 to relate the date of service and the procedures performed to the primary diagnosis listed.  In item 24e, reference only one diagnosis indicator per line of service, from the valid diagnosis codes in item 21.

Also remember that laboratories must submit the diagnosis provided to them by the ordering physician.  Ordering physicians must provide an ICD-9-CM or narrative diagnostic statement on orders/referrals for the laboratories to submit accurate claims.

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

MGS Presents "Topics in Gastroenterology For Primary Care"
The Maine Gastroenterology Society is pleased to announce its May 6, 2006 conference at the Harraseeket Inn in Freeport, Maine.  The conference is entitled "Topics in Gastroenterology for Primary Care" and includes two featured speakers.  Brian Lacy, Ph.D., M.D. received his Ph.D. from Georgetown University and his medical degree from the University of Maryland School of Medicine.  He is Director of the GI Motility Laboratory at Dartmouth Hitchcock Medical Center in Hanover, New Hampshire.  Also speaking will be Lynn Butterly, MD., a gastroenterologist who is passionate about colon cancer screening and is working with health care providers throughout New Hampshire to provide free colon cancer education and screening fairs in local communities.  Dr. Butterly also works at Dartmouth Hitchcock Medical Center.  The Maine Medical Education Trust designates this activity for 6 credits of Category 1 CME, which can be applied toward the AMA Physicians Recognition Award.  Each physician should only claim those credits that he/she actually spent in the activity.  If you would like further information on this event, please contact Gail Begin at 622-3374, ext. 210 or by email at gbegin@mainemed.com to receive a brochure on this conference. [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 the Legal Services for the Elderly’s website at http://www.mainelse.org/partd/formulary_links_physicians.


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.  [return to top]

For more information or to contact us directly, please visit www.mainemed.com l ©2003, Maine Medical Association