April 24, 2006

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Preparing for Public Release of Physician-specific Claims Data
The state legislature, the Maine Health Data Organization and the Maine Quality Forum have all made changes recently in order to have physician-specific data be made available to the public. MMA will devote one of its "First Fridays" CME programs to the topic of preparing for the release of this information. The program will be Friday morning, 9:00am to 1:00pm on Friday, May 5th. Contact MMA at 622-3374 to register.
Since 1993, when the Maine Health Data Organization was established, the physicians name and identifying information on a health claim form (HCFA 1500 or its equivalent) has been confidential.  But the law and regulations have been changed the last 12 months to allow the Maine Health Data Organization to release individual data once it is determined that the data in the all-payor claims data base is complete and accurate.  The all-payor claims data base is contolled by the Data Processing Center, which is a joint project of the Maine Health Data Organization and the Maine Health Infomration Center.

While many observers believe that claims data should not be used to measure quality or to do anything else, beyond paying claims, others believe that claims data can be utilized to provide some data to the public, including such rudimentary metrics as how many procedures of a certain type a physician has performed.

The agenda for the May 5 program is as follows:

  • The all-payor claims database:  Alan Prysunka, Director, Maine Health Data Organization
  • The role of the Maine Quality Forum:  Dennis Shubert, M.D., Director, Maine Quality Forum
  • Pathways to Excellence:  One Approach to the Use of Data:  Ted Rooney, R.N.
  • An Employer's Perspective:  Maureen Kenney, Bath Iron Works
  • Panel DIscussion of Faculty, moderated by Gordon H. Smith

The process to be followed, prior to release of such data, involves the opportunity for a physician to object to the release of the data and the involvement of a group of specialists.  Other requirements apply as well.

There is a $60 registration fee to attend the session,  which includes breakfast and all course materials.  You may register by calling 622-3374 or by visiting the MMA website at www.mainemed.com.


MMA Contracts with Maine Quality Forum to Provide Confidential Practice Self-Assessments
MMA signed a sole-source contract this past week to conduct confidential physician practice assessments that will measure current clinical practice in fifty primary care clinical practices.  Practices that are targeted for the voluntary assessments are small primary care practices which are not part of an established health system or a PHO.  The assessments will be based upon quality measures, tools and metrics to be developed by a physician advisory committee after recommendation by a physician consultant who will be retained to assist the project.

The one-year project will be overseen jointly by the MMA Committee on Peer Review and Quality Improvement and the Maine Osteopathic Association, which will be a full partner in the effort.  Based upon previous communications, several primary care practices have volunteered through one of the two associations to be assessed.  There will be no cost for the assessment.  The assessment will result in a confidential report, protected by the confidentiality provisions of Titles 22 and 32, being provided to the practice. 

Practices assessed will also be able to take advantage of the resources of the learning network being developed by Quality Counts!  A portion of the contract amount will be utilized to provide administrative services to the learning network.

If your practice would like to be assessed, contact Gordon Smith at MMA at gsmith@mainemed.com.  Questions can be directed to Mr. Smith at 622-3374 x212. [return to top]

Legislature to Reconvene; Dirigo Health on the Agenda
The Legislature will reconvene this Wednesday and is hoping to complete action on about 200 bills, including the two bills involving Dirigo Health.  L.D. 1845, which would prohibit health insurers from passing the controversial savings offset payment (SOP) on to premium payers, has been the subject of intense negotiations between various parties, including the Baldacci administration, Democratic legislative leadership, the State Chamber of Commerce, Anthem Blue Cross Blue Shield of Maine and the Maine Hospital Association.  It remains unclear, at this point, whether a compromise can be reached before the end of the week when the legislature is expected to adjourn.

If a compromise does occur, it is likely to include substituting some money from the general fund or the state's reserve fund for some of the SOP, along with the establishment of a Blue Ribbon Commission to report back to the next legislature on recommended changes to the Dirigo program.

The legislature will also consider L.D. 1945 which would permit the Dirigo Health Board of Directors to self-insure the Dirigo Choice Plan as an alternative to the existing Anthem contract, should that alternative become necessary.  [return to top]

Quality Counts! Regroups. Independent Non-Profit Entity Envisioned
At a meeting of interested parties on April 12, including MMA representatives, the Board of Quality Counts! voted to organize itself as an independent non-profit organization.  Previously, the group has operated as an unincorporated collaborative effort among several organizations, housed administratively at the Muskie School in Portland.  The group was organized originally around the effort to advocate for implementation of the chronic care model, now generally referred to as the planned care model.  Since its establishment in 2004,  the organization has put together three very successful conferences aimed at improving the care of chronically ill patients utilizing the chronic care model. 

The new organization will be governed by organizations willing to pay dues to support the organization, which will continue to organize a yearly conference and will also establish a "learning network"  that will assist practices in adopting and implementing state of the art quality initiatives, including the planned care model.

MMA will consider membership in the new organization at the MMA Executive Committee meeting this coming Wednesday (April 26).  [return to top]

Important Message Regarding Payment of Aetna Add-On Code Claims

Aetna and representatives of various state medical societies have reached agreement settling a dispute about the payment of claims for certain "add-on codes."

Under the terms of a lawsuit settlement agreement dated May 21, 2003 Aetna agreed to pay add-on codes from the date they became effective under CPT®. Section 7.20(b)(ii) of the agreement states the following: "'Add-on' codes, as designated by CPT, shall be recognized and eligible for payment as separate codes and shall not be subject to Multiple Procedure Logic." Aetna's systems did not recognize certain codes related to CAD Mammography Services (CPT Codes 76082 & 76083) and Myocardial Perfusion Testing Services (CPT Codes 78478 & 78480) and as a result, these claims were denied. Numerous physicians filed compliance disputes regarding these codes. Aetna has since changed its systems so the CAD Mammography add-on codes have been recognized since April 1, 2005 and the Myocardial Perfusion Testing add-on codes since May 13, 2005.

During the period of April 17, 2006 through July 14, 2006, Aetna will process resubmitted or new claims related to:

  • CAD Mammography Services (CPT Codes 76082 & 76083) provided to Aetna members between January 1, 2004 and March 31, 2005; and/or
  • Myocardial Perfusion Testing Services (CPT Codes 78478 & 78480) provided to Aetna members between January 1, 2004 and May 12, 2005.

Timely filing and appeal deadlines will be waived. Late interest and penalty payments will not apply to these claims. Please note that all other policies will still apply and may impact the ultimate payment of the code(s).

Aetna has posted key information, instructions and forms on www.aetna.com on the "Doctors & Hospitals" main page under "Features" in the lower right corner. Simply click the link titled "Add-On Codes Claims Payment" to access the information. A link will also be posted on the "Claims" main page of the secure provider website. Physician practices can resubmit previously denied claims by listing these claims on spreadsheets and submitting them to Aetna via secure e-mail. New claims can be submitted electronically or via paper, using current standard procedures. Also see http://www.aetna.com/provider/addon_claims_payment.html for detailed information.

For further information about the submission of these claims, or if you are unable to submit via www.aetna.com, please call the Aetna Provider Service Center at 888-632-3862 for Indemnity and PPO-based benefits plans or 800-624-0756 for HMO benefits plans.

Important Message Regarding Two E&M Codes on the Same Day and Modifier -57 Codes

As a result of several disputes and negotiations pursuant to the lawsuit settlement agreement dated May 21, 2003 Aetna has made two important changes in its payment practices impacting: (1) two E&M codes with the same date of service, and (2) allowing an E&M code with a Modifier -57 when billed with a major procedure. Both of these changes are effective February 6, 2006 and are described in detail in various Aetna physician communications. Impacted practices can refile claims with dates of service within 180 days prior to February 6, 2006 by either: (1) submitting the denied claims with a cover letter with a subject line that reads "Rework Request for E&M Codes," or (2) contacting the Aetna Provider Service Center to verbally request rework of the denied claims at 888-632-3862 (Indemnity or PPO based plans) or 800-624-0756 for HMO benefit plans. For more information contact Aetna at the numbers above.

[return to top]

Maine AG Files Lawsuit to Collect Full Tobacco Payment
Attorney General Steven Rowe on Wednesday filed suit in Maine asking the court to declare that the state is entitled to its full annual $50 million payment as part of the historic settlement between the various states and the tobacco companies.  The state had received $44.5 from the companies earlier in the week, but R.J. Reynolds and Lorillard Tobacco Co. together withheld $5.8 million, thus leading to the AG's action.  The companies claim that they have the right to decrease their payment if their market share declines, which has been the case.

The state had anticipated this action and appropriated additional funds in the supplemental budget to cover the shortfall for the existing year which otherwise would have impacted on the Fund for a Healthy Maine.  Unfortunately, in 2007 there is still a potential shortfall of $5.5 million, which could be even larger if Philip Morris joins the other two major companies in withholding a portion of their payment.  The financing problem for the Fund is cured in 2008 as the result of the scheduled increase in payments under the terms of the master settlement.  The scheduled increase would more than cover the potential shortfall from non-payment of the disputed amounts.

Maine has consistently received high marks for its usage of the settlement funds in prevention and cessation activities, with better than expected results.  The state leads the nation in the % of settlement funds going to public health activities. [return to top]

The Coding Center's Coding Tip of the Week
As a primary-care physician, can I submit an office consult on one of my own patients when I have been asked by a surgeon to provide  a pre-op clearance? 
Medicare has said that a physician could report a consultation code for a preoperative clearance on their own patient if all the requirements of a consult are met — that is, the consult was requested by another provider and a written report is supplied to the referring physician. The consultation code can be reported even for an encounter with an established patient. 
That having been said, not all insurances follow these same coding rules (some state that a PCP cannot bill a consult on their own patient, in that case, the preop clearance would be billed as an established patient visit 99212—99215)

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

Health Insurers Have Monopoly Powers

Data in a study by the American Medical Association (AMA) indicates that a handful of health insurers have near-monopolies in many parts of the United States, reports the Boston Globe. According to the study, in more than half of the metropolitan areas examined (166 of 294), a single insurer controls more than half the business in health maintenance organization and preferred provider networks underwriting. The impact of such power on premiums charged and provider payments can be substantial, according to the report. The AMA hopes to use the data to encourage the Justice Department to investigate the possibility of antitrust violations. For more information: [Link via: Boston Globe]

Also, on April 17, 2006, the AMA released its updated report, Competition in Health Insurance:  A Comprehensive Study of U.S. Markets.  The report states that between 1995 and 2005 more than 400 mergers of health insurers and managed care organizations took place and concludes that this consolidation is having an impact on the physician-patient relationship and quality of care.  In 95% of U.S. markets, one insurer had 30% or greater market share and in 56% of U.S. markets, one insurer had 50% or greater market share.  According to the study, two insurers, WellPoint, Inc. (Anthem's parent) and UnitedHealth Group, control 33% of the U.S. commercial health insurance market. [return to top]

Reminder! MAAP Spring Conference Registration (Pediatrics)

Have you registered yet?
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 deadline is April 25th.  Registration information is available online at www.maineaap.org or contact the Chapter Executive Director, Aubrie Entwood, at 685-9358 or agridleyentwood@aap.net. [return to top]

New England AMA Delegation Meeting in Maine this Weekend
The New England AMA Delegation and the Council of New England State Medical Societies will meet at the Black Point Inn in Scarborough this coming Saturday, April 29.  The delegation meeting will focus on resolutions to be considered by or presented to the AMA at the Annual Session in June.  The delegation is chaired by David Simmons, M.D. of Calais.

The Council meeting will feature presentations from each of the state medical societies.   No doubt a lot of the discussion will focus on the recent legislation passed in Massachusetts that is intended to expand coverage to health insurance in that state by imposition of  an individual health mandate.  The Council is chaired by Richard Evans, M.D. of Dover-Foxcroft.

On Friday evening, the Maine delegation will host a reception for our out-of-state guests.  In addition to Drs. Simmons and Evans, Maroulla Gleaton, M.D. of Palermo and John Makin, M.D. of Skowhegan round out the Maine delegation. [return to top]

HHS Health IT "Czar" Resigns Post
On April 20, 2006, the U.S. Department of Health & Human Services announced that David Brailer, the national health care information technology coordinator appointed in 2004, is resigning to become vice chair of the American Health Information Community, an advisory panel to the HHS Secretary.  Dr. Brailer, a physician who was senior fellow at the Health Technology Center in San Francisco prior to his government service, will remain a consultant to HHS on technology issues. [return to top]

May 15th Deadline for Medicare Part D Enrollment Approaching; Extension Unlikely
During a briefing on April 20, 2006, HHS Secretary Michael O. Leavitt said that more than 30 million (of 42 million total) Medicare beneficiaries have prescription drug coverage, including 8.1 million who have voluntarily signed up with PDPs and 5.8 million low-income people automatically enrolled by the government.  If current trends continue, HHS officials estimate that about 90% of Medicare beneficiaries will have drug coverage by the May 15, 2006 deadline.  CMS Administrator Mark B. McClellan said that the federal government felt that holding to the deadline was important and that CMS will conduct 5500 enrollment events across the country prior to the deadline to assist people. 

Physician and consumer organizations in Maine and nationally have expressed concern about the administrative complexity and burden of the new plans.  A working group including the AMA and America's Health Insurance Plans (AHIP) has developed a voluntary uniform appeals and exceptions form called the Medicare Part D Coverage Determination Request Form.  CMS has developed a similar form called the Request for Medicare Prescription Drug Coverage Determination.  It is unclear, however, the extent to which either form is gaining acceptance in the marketplace.

You can find more information about the new Part D drug benefit on the AMA's web site at:  http://www.ama-assn.org/ama/pub/category/12084.html and on Maine's Legal Services for the Elderly, Inc. web site:  http://www.mainelse.org/. [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]

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