July 23, 2007

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Mainecare MECMS Update

Mainecare officials expect to hear this week from the Centers for Medicare and Medicaid Services (CMS) regarding a request from MaineCare to pursue an "accelerated procurement" process in its attempt to replace the flawed MECMS claims management system.  Three vendors are expected to compete to supply a new system that would be based upon a system operating in another state.  ACS, EDS and Unisys all recently presented information on their product and organization to the MaineCare team involved in the selection process.

Although the transition to a new billing and claims information system can typically take up to three to five years, CMS has been asked to approve an accelerated procurement process that would result in a vendor being selected by Jan., 2008 and a new system being operational by Jan., 2010.  The state has received oral communications from CMS indicating support for such a timetable and hopes to have confimation in writing within a few days.

MMA staff has met with representatives of two of the three vendors and will continue to stay involved in the process in an appropriate way.

"Only in connection with the on-going saga of MECMS could a two and one-half year timetable be considered ACCELERATED", noted MMA EVP Gordon Smith following Thursday's MECMS Provider Advisory Committee meeting.  "This means that for the next two and half years, Maine physicians and other MaineCare providers will have to rely on work-arounds and, at times, paper submissions to get paid.  On the other hand, we certainly do not want to repeat the mistakes of the past in turning on a new system too quickly without proper end-to-end testing.  That being the case, I think this is the best we are going to do."

Weekly metrics for the MECMS system showed the following for the week of July 15, 2007.

  • Total claims for the week were 152,455
  • The system processed 93.9% of claims to either payment or denied status
  • Current suspended claims inventory is 77,177
  • In addition to suspended claims, there are unresolved claims in the system with the status of Edits Process Failure.  These 21,327 claims total $34,014,720 in billed charges.  There are also slightly over 10,000 claims caught up in what is called a "fund allocation failure."

There continue to be problems with hospital cross-over claims, physician cross-over claims, voids and adjustments.  A planned work-around to allow physicians to bill electronically for the cross-over claims has been delayed because of unanticipated problems with the hospital cross-over claims fix.

Relative to the recovery of interim payments, approximately 70% of the interim payments have been recovered. MaineCare hopes to collect all the outstanding interim payments by Dec. 31, 2007. Physician practices still hold about $10 million in interim payments but are owed nearly $13 million in suspended claims.   MaineCare has moved forward the automatic claims hold for providers still holding interim payments to April 1, 2007 (it had previously been Oct. 1, 2006).  This change was effective as of July 9.  The automatic hold apparently takes priority over a repayment agreement, which was questioned by MMA.  MaineCare was going to check on that issue but assured attendees that with appropriate and timely communications from the provider, the automatic hold would not apply to offset justified non-payment of interim payments because of on-going claims processing issues affecting the claims of a practice.

Communications were recently sent to anesthesia providers on instructions regarding use of the Anesthesia Modifier 22.  Payment for claims for medically directed anesthesia services has been a continuing problem and hopefully the new plan will result in a successful work-around by paying the claims manually that have not processed electronically.

Payment delays caused by the capping of claims during the end of the state's fiscal year should have resolved by now.  There is no intent to cap claims in the current fiscal year, which began on July 1, 2007.

The Provider Advisory Committee will meet next on August 2, 2007 from 10:00am to noon at the MaineCare offices on Civic Center Drive in Augusta. 

AMA President-elect and MMA President Make "House Call" in Portland

AMA President-elect Nancy Nielsen, M.D. and MMA President Kevin Flanigan, M.D. made a successful "House Call" in Portland on Tuesday (July 17) to inform the media and editorial boards of the access problems likely to be created by the proposed cut in Medicare payments to physicians of 10% on Jan. 1, 2008.   Because of the geographical indices applied as part of the SGR formula, the reduction in Maine is even steeper with physicians in Cumberland and York counties facing an 11.1 cut and physicians in the remainder of the state facing a stunning 12.1 reduction.

While Dr. Nielsen, an internist practicing in Buffalo, N.Y., spoke of the situation nationally, Dr. Flanigan in his remarks brought the problem home to his hometown of Pittsfield, and to similar communities across the state.  Dr. Flanigan practices internal medicine and pediatrics in Pittsfield where he has practiced for the past ten years.

"Like most internal medicine practices in Maine, approximately 45% of my patients are insured by Medicare.  Under this federal plan, I am receiving the same reimbursement today as I did in 2001.  Like most physicians, I may not be able to keep my practice open to new Medicare patients if I am not reimbursed the costs of providing those services.  Until now, I have been able to control costs but not to the extent  that I can handle a 10% reduction in Medicare.  With a shortage of physicians, particularly primary care physicians, looming, who will take care of these patients?", Dr. Flanigan stated in a press conference in Portland and in remarks to the editorial board of the Portland Press Herald/ Maine Sunday Telegram.

Compared to the rest of the country, Maine has the second highest proportion of Medicare patients and the oldest population of any state.  We also have a below-average ratio of physicians to Medicare beneficiaries.  Forty-six percent of Maine's practicing physicians are over the age of 50, an age at which surveys have shown that many physicians consider reducing their patient care activities.  All these factors contribute to the pending access crisis.

The press conference was well attended and resulted in coverage that evening on channel 6, the NBC affiliate and in all the major daily newspapers in the state the following morning.  The editorial visit resulted in a very favorable lead editorial in the Portland Press Herald on Thursday morning, July 19.  In additional, Dr. Nielsen made an early morning appearance on the popular talk radio show on WLOB, the Fox-News affiliate.

The editorial and the complete remarks of Drs. Nielsen and Dr. Flanigan are available on the MMA website at www.mainemed.com under the "What's New" section. [return to top]

Senate Finance Committee Marks Up the SCHIP Legislation

On Thursday, July 19th, the Senate Finance Committee approved the Chairman’s mark of “The Children’s Health Insurance Reauthorization Act of 2007” by a vote of 17-4.  The legislation would reauthorize the State Children’s Health Insurance Program (SCHIP) for 5 years, and would provide $35 billion in new funding for SCHIP on top of the $25 billion that currently exists in the budget baseline. The bill is paid for by increasing the federal tax on cigarettes by 61 cents per pack and also increasing taxes on other tobacco products.  The bill represents a bipartisan agreement among Senators Baucus (D-MT), Grassley (R-IA),  Hatch (R-UT), and Rockefeller (D-WV).  The full Senate will likely consider the legislation prior to the August recess.


The bill would cover 3.3 million more uninsured children and continue coverage for the 6.6 million children currently enrolled.  The bill would not expand coverage to new populations, and would phase out coverage for non-pregnant, childless adults.  It also contains provisions for enhancing outreach and enrollment, as well as to remove barriers to enrollment.  Additionally, the bill provides for premium assistance, which would allow states to use SCHIP funds to enroll SCHIP beneficiaries in employer sponsored insurance if certain conditions are met.

The four Republican Senators who opposed the bill offered amendments (defeated) that addressed three major criticisms:  (1) the bill would continue SCHIP coverage for some adults; (2) according to the Congressional Budget Office, approximately 2 million individuals would be shifted from private insurance coverage to SCHIP; and (3) the bill employs a funding gimmick in order to comply with Congressional Budget rules that would adversely affect funding levels for SCHIP from FY 2013 to FY 2017.    

The legislation does not address the pending Medicare physician payment cuts.  Chairman Baucus stated at the mark up that the Senate will have to act on the Medicare physician payment issue before the end of the year, but that Finance Committee Members have not decided whether to pass their own bill or deal with the issue in the Conference on the SCHIP bill.  Senator Kyl (R-AZ), a longstanding champion for medicine, cited the 10 percent cut facing physicians in 2008 and rhetorically asked when the Finance Committee planned to address it. 

AMA position:  The AMA sent a letter of support on this bill to its four sponsors on July 17th.  This legislation is generally consistent with AMA policy supporting the re-authorization of SCHIP.  The premium support provisions are also consistent with AMA policy on expanding coverage to the uninsured through private insurance.  The AMA strongly supports increasing taxes on tobacco and believes that funds from an increase in the tax should be used to offset the cost of SCHIP reauthorization.  Staff will continue to work with the committee on legislation addressing Medicare physician payment cuts. [return to top]

Housing Resource for Maine Patients/Families Needing Care in Boston

Many Maine practitioners refer patients needing specialized treatments and therapies to hospitals in Boston that are able to provide this kind of care.  Families and friends accompanying these patients need an affordable place to stay while their loved ones receive treatment.  Hospitality Homes provides temporary, no-cost housing in volunteer host homes and other donated accommodations for families and friends of patients seeking care at Boston-area hospitals.  Since 1983, Hospitality Homes’ unique home-away-from-home lodging option has provided a caring response as well as relief from emotional and financial challenges for these individuals and families.  Hospitality Homes is open to all families, regardless of income, nationality, or the patient’s age, diagnosis, or treatment facility.  In 2006, Hospitality Homes provided over 8,500 guest nights to more than 800 guests, saving our guests an equivalent of nearly $750,000 in hotel fees.  Within New England, Maine residents represent the program’s second largest user population.

To refer patients’ families or friends to Hospitality Homes, to request an informational packet, or for a supply of brochures, please call our toll free number @ 888-595-4678 or visit www.hosp.org. An online application for housing is also available on the web site.

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Sign Up for MaineCare's Provider List Serve

Get breaking news immediately by signing up for MaineCare’s provider list serve.  As a subscriber to the list serve, you will get e-mails about the latest changes and updates.    Here’s how:

1)                 Go to http://mailman.informe.org/mailman/listinfo/provider/
2)                 Enter your e-mail address, your name (optional) and select a password.
3)                 Click “Subscribe” and you are done.

List serve messages go out as needed when changes happen.  You can have as many people as you’d like on the list.  In fact, by having more than one of your staff on the list, you will be sure that you get the news even if someone is on vacation. 

Questions?  Call 1-800-321-5557 and select option #9.   [return to top]

MMA Executive Committee Meets this Week

MMA's twenty-eight member Executive Committee meets this coming Wednesday (July 25) at the home of Kevin and Kelly Flanigan in Pittsfield for its summer meeting which traditionally is held at the home of the President.  Despite the slower pace of summer in Maine, the committee faces a full agenda of business items, including:

  • A presentation by Peter Bates, M.D., Chief of Medicine of Maine Medical Center regarding MMC's initiative relative to undergraduate medical education.
  • Further work on the on-going strategic plan, including putting the finishing touches on the Vision Statement and drafting vivid descriptions for the action plans.
  • An update on the 154th Annual Session taking place in Bar Harbor, Sept. 7-9.
  • An update on the results of the AMA Annual Meeting, specifically focusing on the Pay for Performance discussion and the results of the Maine delegation resolution on the Physician Data Restriction Program (PDRP).
  • Initial presentation of a proposed budget for the Association for 2008 and review of the financial performance for the first half of 2007.

The Committee is chaired by Stepahnie Lash, M.D., a practicing neurologist in Bangor.  Agendas and Minutes of the Committee are posted on the members only section of the MMA website at www.mainemed.com. [return to top]

Massachusetts Soon Will Publish Rules on Retail Clinics

Reacting to a proposal by CVS Corporation to expand its Minute Clinic network to a store in Weymouth, MA, the Massachusetts Department of Public Health on July 17, 2007 said that it would release proposed rules to govern such clinics with a limited scope of practice at an August 8, 2007 meeting of the Massachusetts Public Health Council.  The proposed rules also would permit non-profit hospitals or community health centers to open clinics with a limited scope of practice.

The AMA's position on retail clinics may be found in House of Delegates Resolution #160.921, Store-based Health Clinics:  http://www.ama-assn.org/apps/pf_new/pf_online?f_n=resultLink&doc=policyfiles/HnE/H-160.921.HTM&s_t=clinic&catg=AMA/HnE&catg=AMA/BnGnC&catg=AMA/DIR&&nth=1&&st_p=0&nth=4&
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Congress Enacts Tamper-Resistant Pad Requirement for Medicaid; AMA & Pharmacist Groups Object

Title VII of the 2007 supplemental appropriations bill (P.L. 110-28), recently enacted by the U.S. Congress, includes a requirement that all prescriptions in the MaineCare program be written on tamper-resistant prescription forms effective October 1, 2007.  Apparently, the Congress included this as a "cost-saving measure" to offset a moratorium on new federal restrictions proposed for the state share of Medicaid expenses.

Groups including the AMA & the American Pharmacists Association (APhA) have expressed serious concerns about the new law, particularly the short timeframe for implementation.  A number of states, including Maine, have a requirement for tamper-resistant pads for some medications, such as Schedule II medications, but the MMA does not believe that any state requires these special pads for all classes of drugs.

In reaction to these concerns, on July 19, 2007, several Democratic House members introduced H.R. 3090, the Patient and Pharmacy Protection Act of 2007 that would limit the new requirement to Schedule II medications only.  It would not, however, delay the implementation date.

At the direction of the 120th Maine Legislature (L.D. 1728, An Act to Control the Illegal Diversion and Abuse of Prescription Narcotic Drugs & Abuse of Designer Club Drugs, P.L. 2001, Chapter 419; effective 9/21/01), the Department of Public Safety developed Maine Drug Enforcement Agency Rule Chapter 1, Requirements for Written Prescriptions of Schedule II Drugs.  You can find the rule online at:  http://www.maine.gov/sos/cec/rules/16/chaps16.htm. [return to top]

Market Research Firm Seeking Physicians Who Have Patients on Medicare for Discussion Group

Pan Atlantic SMS Group, a long established Market Research Firm located in the Old Port, is conducting a series of discussion groups with Medicare beneficiaries and physicians to gather opinions regarding the Medicare Part D program that began in January 2006. Because the program is relatively new, they are interested in hearing about your experiences using the drug benefit.

A:  Data gathered will provide insight into the physician experience with obtaining medications from the new Medicare drug benefit. This information will allow researchers, plan sponsors and policy makers to better understand the experiences of Medicare beneficiaries, especially regarding cost and drug selection, in order to determine whether adjustments are needed to this new program.

A:  To take part in a nationwide study that will have an impact on your Medicare patients.

A:  Topics will include:

  • Your overall experiences with filling prescriptions under the new Part D plans.
  • Your awareness of plan formularies.
  • Changes in what you prescribe based on your patients’ benefits.
  • Your experiences assisting beneficiaries in choosing plans, etc.

A:  Thursday, July 26, 2007 at 7:00pm

A:  90 minutes

A:  You will receive a $200 honorarium as a way of thanking you for your time.

If you would like more information or if you are interested in participating, please contact:
Tamsin Harwood
Field Research Operations Coordinator
Pan Atlantic SMS Group
Tel: (207) 871-8622 x.102 
Fax: (207) 772-4842 
Email: tharwood@panatlanticsmsgroup.com 
Web: www.panatlanticsmsgroup.com [return to top]

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