December 26, 2006

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Blue Ribbon Commission on Dirigo Health Takes Final Votes

The Governor's Blue Ribbon Commission on Dirigo Health held its ninth and final meeting on December 19 with members casting a series of votes supporting continued financing for the program and recommending design changes and cost reduction strategies.  Of particular interest to MMA was an endorsement of an employer mandate combined with a mandate for individuals with income over 400% of the federal poverty level.   An individual health insurance mandate, requiring  that individuals purchase health insurance policies, has been a central feature of the Association's Plan for Health System reform since 2003.  MMA recognizes that for an individual mandate to be successful, policies would have to be appropriately priced for all demographic groups.

A draft of the Final Report is being circulated to Commission members for their final review.  It is expected to be delivered to the Governor by Jan. 1 and it is further expected that the Commission members will meet with the Governor in early January to discuss their recommendations.

In addition to the recommendations which are detailed below, the Commission voted unanimously to indicate its support for the Dirigo Health Program and its goals. 

The Commission's most important charge was to recommend alternate financing sources for the DirigoChoice program.  Members met that charge by endorsing funding the program at $57 million in calender year 2007 with the funds coming primarily from the General Fund.  Possibilities endorsed by the Commission to generate revenue for the General Fund include taxes on specific behaviors and products that have a negative influence.  Revenues from these sources could be earmarked specifically for Dirigo Health.

  • increased taxes on tobacco products, including smokeless tobacco, specifically with a $.50 increase in taxes on each pack of cigarettes.
  • a snack tax
  • a tax on bottled soft drinks and syrups
  • a tax on beer and wine

In addition, a majority of the Commission supported retaining that portion of the Savings Offset Payment that captures actual savings from reductions in bad debt and charity care as a result of providing coverage to DirigoChoice enrollees.  This amount is expected to be between $5 and $8 million.   In order to determine a fair way to ascertain the actual savings, the Commission recommended the formation of a group of persons consisting of providers, consumers, and insurers to meet with the Dirigo Board and staff as soon as possible.

In the interest of cost reduction, Commission members recommended the following changes in the design and management of the DirigoChoice product. 

  • the program should consider bidding pharmacy coverage separately from the health benefit and should explore purchasing prescription drugs coverage through the multi-state purchasing pool.
  • DirigoChoice should have an option to self-insure, as long as the program maintains a "level playing field" with other small group plans in terms of benefit mandates and legislative oversight.
  • the program should make increased use of focused chronic disease management, with an understanding that savings willl not accrue until after 2007.
  • the program should examine strategies to maximize federal Medicaid matching funds, such as using Medicaid matching funds to pay for employer sponsored insurance, and finding better ways to inform members of potential Medicaid eligibility.

Regarding the target populations for the DirigoChoice program, the Commission voted to endorse the following:

  • the highest priority should be the uninsured and under-insured earning under 300% of the federal poverty level;
  • part-time and seasonally employed adults should be a target
  • Dirigo's definition of a part time worker should, consistent with the state's insurance law, allow employers to offer coverage to employees that work ten or more hours per week; and
  • Adult individuals, sole proprietors, and employees of small businesses are eligible for DirigoChoice subsidy, however marketing should focus on sole proprietors and small businesses.

Regarding making health care coverage more affordable overall, the Commission endorsed the following initiatives:

  • increase transparency of insurance rates by building publicly available data sets that allow consumers and employers to review health plan offerings against a broad set of competitive metrics.  Premium build-up for medical trend, administrative costs, provider pricing (network costs) will be available to the public, as well as groupings of products of similar design and actuarial value to allow informed purchasing decisions.
  • allow sole proprietors to purchase coverage in the small group market
  • require insurers to cover dependents on parents' policy to age 30
  • create options to allow non-subsidized individuals and employees to purchase health care coverage using pre-tax dollars
  • require insurers to give premium discounts for worksite wellness programs and non-smokers
  • review Bureau of Insurance Rule 850 to allow insurers to design plans in such a way as to increase incentives for use of high quality providers.

Regarding individual insurance market reform, the Commission recommends that the Governor appoint a work group representing the Bureau of Insurance, Governor's Office of Health Policy and Finance, consumers, insurers, providers and businesses to begin immediately to conduct an analysis of three options - (1) high risk pools, (2) merger of the individual and small group markets, and (3) reinsurance options applied to the individual market or merged market option - as well as combinations of and different versions of these options and that the results of that study guide policy makers in proposing specific solutions to the individual health insurance market in 2007.

Regarding employer and individual mandates, the Commission endorsed the concept of an employer mandate along with a mandate for individuals with income of 400% of the federal poverty level and recommended that the Governor move forward to explore the parameters of how such mandates would work, including, but not limited to such issues as:  what is considered credible coverage; what would be a reasonable payment for businesses who elect not to purchase coverage; and how the individual mandate would be enforced.

Regarding cost containment throughout the heatlh care system, the Commission recommends that a group be formed to conduct an independent , data driven investigation of cost drivers in health care that effect both providers and payers.

Once Governor Baldacci determines which recommendations to move forward on, the Legislature would then consider a pakage of legislation containing the proposals.




Update on MaineCare/MECMS

The Governor's MaineCare Providers' Advisory Group met on Dec. 21 and heard updates from MaineCare staff on the performance of the MECMS system. 

Week to week, the fesh claims continue to be processed at a high percentage and the suspended claims inventory is under 75,000 for the first time.  However, Group members noted that the paid claims percentage includes claims that are paid incorrectly.  OMS staff acknowledged that the % represents a processing metric and does not reflect claims payment accuracy.  There is, however, a separate review of claims accuracy that is being conductecd currently and that review is expected to be presented to the legislature in January.

For the week ending December 17, 2006, the processing of paid and denied "fresh" claims was 93.4%.  Processing of ALL paid and denied claims was 76%. 

Much of the discussion at the meeting focused on the federally-mandated IV&V  Audit  (Independent Internal Validation and Verification) conducted by First Data Government Services.  The Report of the audit had been released a week prior to the meeting, the release being the result of a Freedom of Information Request filed by a reporter.  As was reported in last week's Weekly Update, the audit report raised doubt about the ability of the original vendor CNSI to complete the project and add the functionality originally promised.

As was reported last week, several observations are made in the IV&V report about poor record keeping and difficult communications between the state and CNSI.  X-Wave and DeLoitte Consulting were brought into the picture in 2005 to assist in areas where CNSI was felt to need assistance.  DeLoitte and X-Wave have been on the scene since, providing technical expertise.  As MMA representatives attend each meeting of the Provider Group, it has been our observation that the expertise of X-Wave particularly has been instrumental in assisting the state but that the underlying flaws in the system relative to increasing functionality still have not been overcome.  It is certainly appropriate at the two year point to review the situation and determine if more drastic action is necessary.

The poor performance of the July 1 release continues to have ramifications down the line, as MMA can no longer get information from the state as to when the MECMS system will be able to electronically process the Pat B cross-over claims or when the system will be HIPAA compliant.  "Void functionality" is the major development currently underway with the goal to have functionality in place sometime during the first quarter of 2007.  This scheduling would mean that the electronic processing of the Part B crossover claims would have to wait until well into 2007, a full two to three years after the system went live in Janaury , 2005.

Relative to the promised reimbursement of provider interest cost due to borrowing because of MECMS, a letter is being prepared by Deputy Commissioner Kirsten Figueroa which will be sent to all providers.  The letter will include information on what evidence needs to be sent to the state in order to be eligible for reimbursement.

When questioned about the impact of the IV&V audit and the resulting newspaper articles stating that the OMS was considering scrapping the MECMS system in favor of out-sourcing the payment of claims, OMS staff would not comment on the report and indicated only that all information would be considered and that a decision would be made within the next two months. 

Provider Group members, including MMA EVP Gordon Smith, have asked for one-half hour to be set aside during the next meeting on Jan. 4, 2007 to discuss the IV&V audit report.

Relative to the return of interim payments, the balance outstanding is $212.1 million.  The message to providers going forward is that the interim payments represent overpayments that need to be paid back.  If a practice is asked to return an interim payment(s) and believes it is owed off-setting payments still suspended or otherwise unpaid, the practice should communicate with the Interim Payment Recovery Team (IPRT) as soon as possible.




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Collecting What You are Due: Collections Seminar Feb. 2, 2007 at MMA

MMA's popular practice education offerings called, "First Fridays" are offered the first Friday of each month at the Frank O. Stred Building in Manchester which houses MMA's offices.  Offered from 9:00am to noon, the programs normally are certified for category one CME and offer a range of subjects.  The cost is $60 which includes breakfast and all course materials.

The first program of 2007 is being offered on Friday, Feb. 2 and the topic is collections.  Learn how to collect what you are due and help ensure compliance with exisiting state and federal laws.  With more patients having high deductibles and with the advent of HSA plans, accounts receivables are climbing.  At the program, Vaughn Clark of the Thomas Agency will be presenting up to date materials on how to get paid what you are due.  Other faculty may be added as well.  Gordon Smith, Esq., will assist on the issue of legal compliance.

Registration forms were included in the Nov/Dec. issue of Maine Medicine but you may also call 622-3374 (press O for assistance) to register.  Best of all, you may register on the MMA website at (Click on "Programs, Seminars & Events" on the left-hand side of the home page.) [return to top]

Legislative Committee Assignments Announced

Late last week, the presiding officers of the 123rd Maine Legislature announced committee chairs and assignments for the new legislature. 

The chairs of the key committees having jurisdiction over health care policy are:

  • Joint Standing Committee on Business, Research & Economic Development:  Senate Chair, Lynn Bromley (D-Cumberland); House Chair, Nancy Smith (D-Monmouth)
  • Joint Standing Committee on Health & Human Services:  Senate Chair, Joseph Brannigan (D-Cumberland); House Chair, Anne Perry (D-Calais)
  • Joint Standing Committee on Insurance & Financial Services:  Senate Chair, Nancy Sullivan (D-York); House Chair, John Brautigam (D-Falmouth)
  • Joint Standing Committee on Judiciary:  Senate Chair, Barry Hobbins (D-York); House Chair, Deborah Simpson (D-Auburn)
The chairs of the two financial committees are:
  • Joint Standing Committee on Appropriations & Financial Affairs:  Senate Chair, Margaret Rotundo (D-Androscoggin); House Chair, Jeremy Fischer (D-Presque Isle)
  • Joint Standing Committee on Taxation:  Senate Chair, Joseph Perry (D-Penobscot); House Chair, John Piotti (D-Unity)
Both physicians in the 123rd Legislature will sit on the Health & Human Services Committee.  Representative Robert Walker, M.D. (R-Lincolnville), a radiologist, will be the lead Republican House member on the committee.  Senator Lisa Marrache, M.D. (D-Kennebec), a family physician, will be the second Senator from the majority party on the committee.  She also will chair the Joint Standing Committee on Legal & Veterans Affairs. 

You can find the full committee memberships on the legislature's web site at:  

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MEMGMA Announces 2007 Third Party Payer Seminars

The Maine Medical Group Management Association is Pleased to Present:


Two Dates and Convenient Locations:
Wednesday, January 10, 2007
Ramada Conference Center, 490 Pleasant Street, Lewiston, Maine

Wednesday, January 17, 2007
Jeff’s Catering, 5 Coffin Avenue, Brewer, Maine

Provider representatives from the major payers will be speaking at this seminar and providing updates as to the status of claims processing. Representatives from the following insurance companies have been scheduled to attend:


(** Brewer Only)

Participants will have the opportunity to ask questions concerning reimbursement issues affecting physician practices in general, but should not expect answers to questions concerning individual account situations.

Seminar Schedules:

  • Registration for both seminars begins at 8:30 AM.
  • Continental breakfast served at 8:30 AM.
  • Sessions begin at 9:00 AM.
  • A full buffet lunch is included with registration.
  • Speakers for each insurance company may be
  • presenting at different times each day, so an exact
  • schedule is not available.
  • The final speaker will conclude by 4:00 PM.

Registration Information:

  • Space may be limited at both locations so please register as early as possible by phone or mail.
  • The cost for either seminar is only $40.00 for
  • MEMGMA members or $50.00 for non-members.
  • If you have questions concerning this seminar, or for
  • late registration, please contact Kim Anderson at (207)
  • 774-8277 or at
  • Please print and complete the registration form and send to the address specified.
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Report: HIPAA Privacy Rule Violations Under-investigated

According to Government Health IT, a report issued by Melamedia, LLC, raises concerns that the U.S. Department of Health and Human Services' (HHS) Office for Civil Rights (OCR) may not be taking violations of the Health Insurance Portability and Accountability Act's (HIPAA) privacy rule seriously. Of 22,964 privacy complaints submitted to HHS from April 2003 through September 2006, OCR investigated only 5,400 cases-a rate of less than 25 percent. Of those 5,400 complaints, OCR took formal action in 3,700, while absolving the accused health care organizations in 1,700 others. No explanation is given for the low percentage of investigations. For more information:


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Pathways to Excellence: Update

The physician data collected by the Pathways to Excellence Project  in 2006 will be available on the website of the Maine Health Management Coalition (MHMC) beginning Friday, Dec. 29, 2006.  The website address is . Compared to previous years, there are new sections for the blue ribbons, office system surveys, outcomes and process measures.  For the first time, the adult and pediatric practices are separated.

For process and outcomes measurements, PTE is only reporting practices that attest that all of their patients are included in the denominator.  PTE is also currently using a minimum of 15 patients to report a practice, otherwise it uses "not enough data" in this section.

Pathways to Excellence in 2006 voluntarily received data from more than 60% of the primary care practices in the state.  An initiative is underway to work with some of the major specialties to develop a program of voluntary reporting in 2007.  The initial specialties include cardiology, surgery (including specifically neurosurgery), radiology, orthopedic surgery and ob-gyn.

The data on the Coalition website is used specifically for employees of companies in the MHMC but any person can get into the public portion of the site and review what is available. [return to top]

The Coding Center's Coding Tip of the Week

The Golden Rule

  • Only one Evaluation and Management service may be reported per day by the same practitioner.
  • There are 2 major exceptions to this rule (there are others, i.e. hospital discharge and nursing home admit, but these are the most common):
    • Critical Care done on the same date of service as a problem visit—generally these are done at separate times of the day.  Be sure that diagnosis supports the critical care service 
    • Preventive service on the same date of service as a problem visit—generally done at the same encounter.  Be sure that diagnoses used supports each service (i.e. the preventive visit should be billed with a “V” code for general medical exam)
Questions? Call the Coding Center: 1-888-889-6597 [return to top]

MaineCare DUR Committee to Consider PA for Suboxone on Jan. 9, 2007

At its next meeting on Jan. 9, 2007 (6:00pm at DHHS offices in Augusta), the MaineCare Drug Utilization Committee (DUR) will review its proposed prior authorization requirements for Suboxone.  At its November meeting, committee members tabled action on the possible prior authroization of Suboxone until  the Jan. meeting in order to further evaluate concerns that had been expressed by many physicians and other clinicians. 

The comments and criteria regarding the drug, which is listed as a preferred drug,  which have been published in the MaineCare Preferred Drug List for 2007 are as follows:

 (Comment)    Suboxone is preferred with max dosing limits of 32mg daily if the following conditions are met: a.) There is not another Suboxone script in member's drug profile within the past 30 days and b.) There is not more than one narcotic fill in member's drug profile between today's fill of Suboxone and a prior Suboxone fill within the past 90 days. (There...) Should be evidence provided of monthly monitoring including random pill counts, urine drug tests and prescription monitoring program reports.

(Criteria)  Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preffered drugs will be approved, unless an acceptable clnical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists.  Subutex will only be approved for use during pregnancy.

Physicians interested in office-based opiod treatment may wish to comment on the criteria prior to the Jan. 9th meeting.  Comments can be addressed via e-mail to or via regular mail to Jessica Oesterhold, M.D., Director DUR & Medical Education, DHHS, 11 State House Station, Augusta, Maine 04333-0011.  You may also fax comments to Dr. Oesterhold at 207-287-2675.

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TMA Slams Doctor-Rating System

The Austin Business Journal, December 13, 2006
In response to protest by the Texas Medical Association (TMA) over BlueCompare, a physician rating system created by Blue Cross Blue Shield of Texas, the insurer has shut down the program. BlueCompare attempted to rank physicians using insurance claims and health care bills instead of evaluating quality of care from patients’ actual medical records. Ladon W. Homer, MD, president of TMA noted that ranking physicians based on insurance claims is ridiculous because “you can no more tell from looking at a claim form that good medical care was provided than you can tell from looking at a restaurant bill that good food was served.” TMA also feared that patients would find the rating system confusing because BlueCompare awarded blue ribbons to those physicians who fall into the top 60% of its quality rankings but awarded gray ribbons to those doctors who ranked in the bottom 40% and those physicians for whom it did not have enough claim forms to rate. Gray ribbons were also granted to physicians in specialties for which Blue Cross has no rating system. TMA and Blue Cross are scheduled to meet to discuss BlueCompare among other transparency and quality issues. [return to top]

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