May 15, 2006

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Dirigo Health Board Finds $41.5 Million in 2007 Savings
The Dirigo Health Board on Friday issued its decision on the 2007 Savings Offset Payment, finding that the Dirigo Health reforms had saved $41.5 million last year in overall health care costs. In additional to finding savings from reductions in bad debt and charity care, the Board, once again, has included additional savings from hospitals voluntary compliance with limits on net operating margins, certificate of need restrictions and even savings from the MaineCare fee increase for physicians.
The estimated savings estimate will now be reviewed by Insurance Superintendent Alessandro Iuppa who is charged with making the final decision.  The "Savings Offset Payment" (SOP) , which is collected from insurers and self-insured businesses, accounts for the major funding of the Dirigo Health initiatives, including the DirigoChoice product.

The $41.5 million is down slightly from the $43.7 SOP applied in 2006.  The preliminary calculations filed by the Dirigo Health Agency on May 2, 2006, indicated that the agency had determined that there were $100 million in savings through December 31. 2006.  This figure included an estimated $8.2 million in savings as the result of the MaineCare physician fee increase that was effective July 1, 2005.   The preliminary report was prepared for the Dirigo Health Agency by its consultant, Mercer Government Human Services Consulting.

Last year's SOP is still the subject of litigation brought against the Agency by the Maine Association of Health Plans and other business organizations.

In legislative action last month, a compromise developed by interested parties was given a favorable committee recommendation.  The compromise, among other things, would reduce the current SOP from $43.7 million to $23 million.  The compromise also shifts $11 million from Anthem to Dirigo through a reduced experience modification program in calender year 2006 and requires the Dirigo Health Agency to reduce its administrative expenses by  $1.9 million.  In addition, the majority committee report establishes a 15 member Blue Ribbon Commission on Long-term Funding of the Dirigo Health Program.  The Commission is charged with studying the Dirigo Health Program and making recommendations for a long-term funding mechanism.  The physician community will be represented by at least one person on the Commission.  The Commission would report to the Legislature by Nov. 2007.

MMA supports the compromise legislation.

MMA and MOA to Offer Primary Care Self-Assessments Sponsored by Maine Quality Forum
The Maine Medical Association has recently signed a contract with the Maine Quality Forum to offer confidential self-assessments for primary care practices across the state.  The funding from the Forum will make it possible to offer the self-assessments at no cost to the practices.  Once the metrics for the project has been developed by a physician advisory committee to the Project, a chart reviewer will come to the office of a Project participant and conduct the assessment.  A confidential report will then be sent back to the practice.

The target practices are those that do not belong to a PHO and are not owned by a hospital, although all practices volunteering will be considered, regardless of their affiliation and ownership.

The Project will be limited to 50 practices.  If you would like your practice to be one of the 50 practices assessed, please contact Gordon Smith at

The contract with the Maine Quality Forum also provides funds for staff for the Quality Counts! Learning Network.  The goal of the learning network is to connect interested practices to resources that will assist in promoting the planned care model, formerly called the chronic care model. [return to top]

HealthInfoNet (formerly MHINT) Receives $1 Million Challenge Grant; Hires Executive Director
HealthInfoNet, formerly called the Maine Health Information Network Technology project, has received a $1 million challenge grant from the Maine Health Access Foundation.  The grant, which will match funds raised from May 2006 through December 2007, is intended to help spur the fundraising effort to implement the first HealthInfoNet demonstration project.  The grant represents one of the largest grants given by the Foundation since it began making grants in 2002.  It is also the first time the Foundation has provided a challenge grant, requiring the grantee to raise matching funds.

The HealthInfoNet Board also announced last week that it had hired its first Executive Director, "Dev" Culver.  Culver previously served as Chief Information Officer at Eastern Maine Health Care for 16 years prior to leaving Maine in 2004 to assume senior positions at two national health care information technology firms.  He will begin his position for the Board in June.

HealthInfoNet is currently in the second phase of  the project that was originally called the MHINT project.  The organization is developing a statewide network giving authorized healthcare professionals and hospitals immediate access to a patient's medical record.  It is anticipated that patients would have the opportunity to opt out of the system.  

Physicians on the 19 member board include Roderick Prior, M.D. of Farmington and David Howes, M.D. of Martin's Point.  Additional physicians are included on an advisory committee.

As a result of the efforts of HealthInfoNet, Maine is one of nine states selected by the American Health Information Management Association (AHIMA) to begin a project to quickly develop a national consensus for best practices for state-level regional health information organizations (RHIOs).  The AHIMA announced the project, funded by the Office of the National Coordinator for Health Information, on May 8, 2006.  The project's goal is to produce public domain information on RHIO best practices in governance, structure, financing, operations, and health information exchange policies and its estimated completion date is August 3,1, 2006.  The other eight states chosen are California, Colorado, Florida, Indiana, Massachusetts, Rhode Island, Tennessee, and Utah.  The AHIMA is an association of 50,000 members based in Chicago.  [return to top]

Ad Hoc Committee on Health System Reform to Meet with Insurance Superintendent Al Iuppa on Tuesday
The MMA ad hoc Committee on Health System Reform will meet Tuesday night with Bureau of Insurance Superintendent Alessandro Iuppa on Tuesday night at 6:00pm at the MMA offices in Manchester.  The Committee has been charged with the task of reviewing and updating the Association's White Paper prepared in 2003 on universal access to care. The purpose of meeting with the Superintendent is to review several insurance-market issues such as guaranteed issue and community rating.

Any interested MMA member is welcome to attend the meeting, but please give us a call as dinner is being served and we want to be sure to have enough food for those present.  Call Charyl Smith at 622-3374 ext. 211 if you are planning to attend.

MMA President Jacob Gerritsen, M.D. chairs the committee. [return to top]

Today is Deadline for Seniors to Sign Up for Medicare Part D
There was a lot of activity last week focused on the Medicare Part D prescription drug benefit.  There was a last minute push by CMS, state agencies and senior advocates encouraging seniors to select a plan by the close of business Monday, May 15, so that they will not be subject to the additional premium imposed as a penalty for those who do not sign up by the deadline.    After Monday, premiums will increase 1 percent each month.  The penalty of a seven-month delay - waiting to sign up in Jan. of 2007 -would result in a $1.75 increase to the average monthly premium of $25.

Seniors groups and many office holders,including Senator Olympia Snowe, have called upon the federal government to delay the deadline but so far, the deadline has not been changed.  About 31 million Medicare recipients have signed up for a plan, with about 9 million signing up for a stand-alone plan.  The remainder belong to a Medicare HMO plan. 

Low-income persons (those earning up to $14,700 per year and have no more than $11,500 in assets) face no penalty for enrolling late.  Nor do seniors who are covered with private insurance so long as that insurance is determined to be comparable or superior to that offered by the Part D benefit. [return to top]

Executive Committee Vacancy in Knox County: Call for Nominations
Paul Klainer, M.D. of Rockland has resigned from the MMA Executive Committee creating a vacancy in the position representing Knox County physicians.  Dr. Klainer will continue to serve as Chair of the Association's ad hoc Committee on Technology.  Any MMA member from Knox County interested in being considered for the Executive Committee position should contact Gordon Smith at or be calling 622-3374 ext. 212. 

The Executive Committee meets about 8 times a year, usually on Wednesday afternoon at 2:00pm.  The meetings are generally held at the Frank O. Stred building in Manchester, except for the summer meeting and the meetings held at the Annual Session.  There are 28 physicians on the Committee. [return to top]

Report from MaineCare Providers' Advisory Group (MECMS) Meeting May 11
The MECMS Provider Advisory Committee met on May 11.  The weekly metrics showed that over 88% of fresh claims were processed for the week ending May 7, with just over 11.50% of claims going into suspension.  Of concern is the increase in the total of suspended claims which two weeks ago was down to a low of 180,215.  But the last two weeks have each seen an increase in the number of suspended claims with the week ending at 204,197.  As the trend previously had been downward, this upward trend is of grave concern.

Also of concern is the federal Coordination of Benefits Agreement Program (COBA) taking effect on July 1, 2006.  The impact of this new process on the systems ability to electronically process the Part B cross-over claims is currently unknown.  In the meantime, billing existing or old cross-over claims on paper seems to be the best option.

The Fiscal Year 06 goal of recovering $225 million of the interim payments has been met, with just over $236 million collected or promised under contracts.   MaineCare is preparing the necessary business processes to begin conducting business with providers in HIPAA compliant Electronic Data Interchange (EDI) formats.  The process will include registration, signing a Trading Partner Agreement and a validation process for provider submitted files.  A testing process is anticipated to begin in July 2006.  The first transactions to be covered include:

  • TA 1 Acknowledgment Acknowledgement
  • 997 acknowledgment acknowledgment of receipt of 837
  • Claim Transaction Provider Testing
  • 837 Claims 8371:  Institutional
  • 835 Claim Payments

Other HIPAA transactions will be folded in over the course of the next few months.

The Committee will meet next on Thursday, June 8 and may begin to meet monthly rather than twice per month after members are polled on the topic.  MMA will vote to continue the more frequent schedule.  We remain frustrated with the slow progress and believe that the twice-monthly meetings help keep the Department's feet to the fire. [return to top]

Next "First Fridays" Educational Program on Common Coding Errors: Friday June 2
The next MMA First Friday program will be presented on Friday, June 2 and will feature the staff of The Coding Center discussing common coding errors.  Jana Purrell, Director of the Center will share with attendees the most common problems found out in the practices and will discuss techniques on how to keep your coding complaint with the regulations of payors.

The programs runs from 9:00am to noon and will be held at the MMA offices in Manchester.  For registration materials, contact Jess Violette at 622-3374 (press 0).  The cost for the program is $60 which covers breakfast and all course materials. [return to top]

The Coding Center's Coding Tip of the Week
Can we code for a condition that is listed as :  “Probable”, “suspected”, “questionable”, “rule out”, or “working diagnosis”?
Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis”. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as signs or symptoms, abnormal test results, or other reason for the visit.
For example:  if a patient presents with a sore throat (pharyngitis) and the provider is going to “rule out strept”—the diagnosis submitted on the claim form should be pharyngitis (462) rather than strept (034.0)

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

Study: Tort Reform Effective in Reducing Medical Liability Premiums

A new study finds that tort reforms are the best proven instruments for reducing medical liability insurance premium growth, reports Insurance Journal. The study, conducted by Stanford University and funded by the Physician Insurers Association of America, found that increased claims costs are the primary driver of premium rate increases. Tort reforms decrease claims costs, which results in lower premiums for physicians. The study also found no evidence to support the argument that anticompetitive behavior, weak regulation or insurer investment decisions are important contributors to rising premiums. For more information:

To read the report: [return to top]

"Involuntary Mental Health Commitment Hearings: Protecting Civil Rights" Seminar, June 13
Involuntary Mental Health Commitment Hearings: Protecting Civil Rights
June 13, 2006, 8:30 - 4:00
Maple Hill Farm Conference Center, Hallowell, Maine
Sponsored by
The DHHS Office of Adult Mental Health Services & the Office of the Attorney General
in collaboration with the USM, Muskie School, Center for Learning

Maine's commitment law allows an individual to be admitted involuntarily to a psychiatric hospital when it has been determined that the individual poses a likelihood of serious harm due to a mental illness.   Involuntary commitment is a serious infringement of an individual's civil rights and, by statute, should be available only as a last resort. 

Through panel presentations, video vignettes, and group discussions, this conference will explore legal and clinical issues to be considered in involuntary commitment, including alternatives to hospitalization, and will provide strategies for how best to represent an individual in an involuntary commitment hearing.  Presenters and panelists will include lawyers who represent hospitals and patients in commitment hearings, clinicians who treat involuntary patients, consumers of mental health services, and Active Retired Judge Courtland D. Perry, who drafted Maine’s original commitment law and routinely hears involuntary commitment hearings.

This program is designed for lawyers, doctors, judges, mental health professionals and other individuals involved in or interested in the mental health commitment process.

For questions regarding registration, call Linda Kinney at 626-5231
[return to top]

U.S. Senate Republicans Fail to Pass Bills During "Health Week"
As expected, the U.S. Senate failed to reach the 60 votes necessary for cloture on two medical malpractice bills debated on the floor without committee work last week.  The proposed Medical Care Access Protection Act of 2006 (S. 22), including a "stacked cap" of $250,000 from a health care provider and $250,000 from two institutions (for a total of $750,000) garnered only 48 votes and a bill (S. 23) focused on OB/GYNs received 49 votes.  Three Republicans, Michael Crapo (R-ID), Richard Shelby (R-AL), and Lindsey Graham (R-SC) voted with Democrats against both bills.

The Republican leadership in the Senate also failed to pass legislation, the Health Insurance Marketplace Modernization & Affordability Act of 2006 (S. 1955), designed to help small businesses provide health care coverage.  S. 1955 failed 55-43 in a mostly party-line vote. [return to top]

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