August 13, 2007

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Congress in Summer Recess; More Work to be done on SCHIP/Medicare Payment

While Congress is in its traditional summer recess, The AMA, MMA and virtually all national and state medical societies are at work shoring up support for the reauthorization of the State Children's Health Insurance Program (SCHIP) and for Medicare payment reform.  Without a successful reconciliation between the House and Senate on the differences between S. 1893 and H.R. 3162 and the President's signature on such a bill, the current SCHIP program will expire on Sept. 30 and physician payments from Medicare will be reduced by 10% effective Jan. 1, 2008.  All four of Maine's congressional representatives have expressed support for an SCHIP reauthorization and a Medicare payment reform bill which would, at a minimum, restore the scheduled cut.

In early August, both the House and Senate passed bills reauthorizing the SCHIP program, but there are many significant differences in the two bills and the Senate bill does not contain the Medicare physician payment reform. 

On the Senate side, S. 1893, the Children's Health Insurance Program Reauthorization Act of 2007 (CHIP Act) reauthorizes the SCHIP program for 5 years.  It would cover 3.3 million more uninsured children, in addition to continuing coverage for the 6 million children already enrolled.  It provides $35 billion in new funding for SCHIP over the 5 years, on top of the current $25 billion baseline.  It would be paid for by a 61 cent per pack cigarette tax increase and increases in taxes on other tobacco products.

The House bill, H.R. 3162 the Children's Health and Medicare Protection Act of 2007 (CHAMP Act), also reauthorizes SCHIP for 5 years, on top of the current baseline.  It would be paid for by a 45 cent per pack increase in cigarette taxes and by a reduction in subsidies currently paid to health plans offering Medicare Advantage plans.

The Senate bill reduces financing available to states that extend SCHIP to children in families whose effective income would exceed 300% of the Federal Poverty Level, with an exclusion for certain income applying "income disregards."  The House bill proposes no change in the current income eligibility level of 200% of FPL, but permits state waivers covering certain individuals with incomes above 200%.

The AMA strongly suuports reauthorization of SCHIP and covering all children who are eligible for coverage under the program.  The AMA also strongly supports raising the federal income tax on cigarettes and other tobacco products and suuports the reduction in overpayments to Medicare Advantage plans.  The AMA supports $60 billion in new SCHIP funding, more than the appropriation in either bill.

As reported in last week's Weekly Update, the house bill (CHAMP) prevents a 10% cut to Medicare physician payments in 2008 as well as a projected 5% cut in 2009 and instead provides .5% (one half of one percent) updates in 2008 and 2009.  The cost for this SGR fix is over $20 billion over 5 years and over $67 billion over 10 years.

Other details of the package can be found on the MMA website at  Look under the What's New section.  Detailed comparisons of the two proposals will be on the website later this week.

MMA Signs on to Letter Asking for CMS to Delay Requirement for Tamper-Resistant Prescription Pads

MMA signed onto a letter this week, authored by the national organization of chain pharmacies with assistance from the AMA, urging a delay in, and further consideration regarding the new federal statutory Medicaid mandate which requires that ALL Medicaid prescriptions be written on tamper-resistant prescription forms beginning Oct. 1, 2007.  The provision was inserted into a recent military funding measure (Section 7002(b) of the U.S. Troop Readiness, Veterans' Care, Katrina Recovery, and Iraq Accountability Appropriations Act of 2007: P.L. 110-28).

As of August 12, the Centers for Medicare and Medicaid Services (CMS), which will be administering and enforcing the requirement, has not issued any guidance to State Medicaid directors and no such guidance is expected until early September.  That being the case, there will not be sufficient time for practices to purchase prescription pads that would be in compliance with the requirements.  While Maine is one of approximately 15 states which require such pads for schedule II narcotics, most physicians MMA has heard from regarding this requirement have indicating that it would be a hardship to use these scripts for all prescriptions.

Implementation issues include whether a sufficient number of pads would be available nationwide, the specifications for the pads and their cost.  MMA does have a favorable pricing arrangement for members through RX Security and its pads have been found to be in compliance with Maine law.  The company can be contacted at or by calling 1-800-667-9723.

The August 8 letter requesting a delay noted concern about the potential for delays in MaineCare beneficiaries receiving their medications caused by uncertainty over what action a pharmacist should take if a prescription is written on non-tamper-resistant paper.  Under the new federal requirement, prescriptions not written on the mandated forms will be ineligible for Federal matching funds.  A pharmacy faced with the possibility of having its reimbursement denied or recouped for a noncompliant script could be put in the difficult position of being unable to fill that prescription or having to delay dispensing crucial medication until the prescriber can be contacted to rewrite the prescription on the specified form. The administrative hassle on the medical practice must  be considered as well. The authorizing legislation does not specifically permit the dispensing of an emergency supply until a proper script can be executed.

In meetings with CMS officials, they have expressed concern over their ability, legally, to impose a delay or to permit an emergency exception to the statutory requirement.  The AMA and other organizations will seek legislation implementing a delay, but with the Congress currently in recess and with few pieces of legislation likely to be enacted prior to Oct. 1 to attach the legislation to, practices should be prudent and be prepared for implementation on that date if a delay can not be achieved. [return to top]

2007 AMA State Advocacy Roundtable Meeting Addresses Current Issues

MMA governmental affairs staff attended the AMA's 2007 State Advocacy Roundtable Meeting in Colorado this past week.  Over 100 attendees from state medical societies and national specialty societies discussed issues ranging from universal access to medical liability reform.  Individual topics included the following:

  • State Efforts to Expand Access to Health Insurance
  • Legislating the Use of Physician Prescribing Data
  • Physician Ownership Issues (CON, Specialty Hospitals, etc.)
  • Medicare Payment Reform
  • Private Sector Advocacy
  • Managed Care Payment Practices
  • Tiering of Physicians
  • Scope of Practice Issues
  • Medical Liability Reform

MMA EVP Gordon Smith led the discussion on the physician prescribing data, describing the three different legislative approaches enacted in New Hampshire, Vermont and Maine.  Mr. Smith chairs the Executive Committee of the Advocacy Resource Center which organizes the yearly conference.  Deputy EVP and General Counsel Andrew MacLean also attended the conference. [return to top]

154th Annual Session, Sept. 7-9, 2007 in Bar Harbor

Make plans now to join your colleagues in Bar Harbor Sept. 7-9, 2007 at the Association's 154th Annual Session.  Seven and one-half hours of category one CME are available with the theme being, "Maine Medicine 2020:  New Horizons."  Attendees will hear from several speakers who will try to predict what medicine will look like in Maine in the year 2020.  What will coverage mean at that time?  Will universal access have been achieved? 

A limited number of rooms are still available at the Harborside Hotel despite the room block expiring on August 10.  There are also many other nearby hotels and B&B's which are available for your use.

Specialty meetings involving urologists, orthopedic surgeons and psychiatrists will take place, with the orthoopedic surgeons presenting their own CME program featuring Red Sox and Patriots team physician and orthopedic surgeon Thomas Gill and former AAOS President James Herndon, M.D.  Dr. Herdon will also speak as part of the MMA closing session on Sunday morning.

The session begins with a keynote luncheon on Friday, Sept 7 at noon, featuring Charles Baker, President and CEO of Harvard Pilgrim Health Care and a former health commissioner in Massachusetts.  Mr. Baker will discuss the recent reform efforts in Massachusetts.  Responding to his talk will be Kelly Kenney with the AMA and Paul Harrington, EVP of the Vermont Medical Society.

Over 35 companies and firms will exhibit in the exhibit hall at the meeting.  Three hundred total attendeees are expected.  We hope you will be one of them.  Should you have any questions, please call the MMA office at 622-3374.  Press option 0 and anyone answering the phone can assist you with registering for the meeting. [return to top]

2007 Physician Quality Reporting Initiative (PQRI) Update

It’s been one month since reporting quality data codes for the 2007 Physician Quality Reporting Initiative (PQRI) on claims for dates of service starting July 1 through December 31, 2007 began. Eligible professionals participating in the 2007 PQRI indicate that the PQRI Tool Kit and Data Collection worksheets are an asset to successful reporting. Provider organizations report successful reporting by their members. Information about the 2008 PQRI was released in the Notice of Proposed Rulemaking for the 2008 Medicare Physician Fee Schedule.
To ensure successful reporting, the Centers for Medicare & Medicaid Services (CMS) would like to bring to your attention the following items:
Use of Modifiers with PQRI Quality Data Codes
The PQRI quality data codes should only be reported with CPT II modifier(s) (1P, 2P, 3P or 8P), if applicable.  If any other modifier, i.e. CPT I modifier or HCPCS Level II modifier, is placed on the same line as a PQRI code, it may cause the claim to be rejected or denied as an invalid procedure/modifier combination.
Reminder: PQRI Letter to Medicare Beneficiaries
CMS has posted a letter to Medicare beneficiaries with important information about the PQRI at,, on the CMS website. The letter is from Medicare to the patient explaining what the program is, and the implications for the patient. Physicians may choose to provide a copy to their patients in support of their PQRI participation. 
Question of the Week
Question: The 1.5% bonus is subject to a cap. How and when will CMS calculate the cap for an individual eligible professional?
Answer:  The bonus cap calculation is defined as follows: (the individual's instances of reporting quality data) multiplied by (300%) multiplied by (the national average per measure payment). The third factor, the "national average per measure payment amount" can only be calculated after the reporting period ends because it is equal to (the total amount of allowed charges under the Physician Fee Schedule for all covered professional services furnished during the reporting period on claims for which quality measures were reported by all participants in the program) divided by (the total number of instances where data were reported by all participants in the program for all measures during the reporting period.)
Because the "national average per measure payment amount" is not yet available, the following is a hypothetical example:

  • Dr. Smith had $400,000 in allowed charges during the PQRI reporting period.  
  • The 1.5% potential bonus is $6000.
  • Dr. Smith reported quality data codes in 500 instances.  
  • The national average per measure payment amount for 2007 was calculated in CY 2008 and turned out to be $100 ($100 M total national allowed charges claims submitted from July through December, divided by, 1 million instances of PQRI quality data codes being reported in the same time period).  
  • The cap for Dr. Smith is $150,000 (500 x 3 x $100). 
  • The bonus paid to Dr. Smith in early CY 2008 is $6,000.

How to View the Measures and Specifications
To view the entire list of 2007 PQRI quality measures and the associated measure specifications, visit the PQRI website at,, and click on the “Measures/Codes” section of the page.
How to View the List of Eligible Professionals
To see the complete list of eligible professionals who may choose to participate in the 2007 PQRI, visit the PQRI website at,, and click on the “Eligible Professionals” section of the page.
PQRI Resources
New information is continually added to the most reliable source of information for the 2007 PQRI, the CMS website, Here you will find new and revised Frequently Asked Questions, updates on issues related to both the 2007 and 2008 PQRI, new educational products, and access to the latest information you need to successfully participate in the 2007 PQRI.
General Information
Rejected Claims
Fee-for-Service Medicare claims can be rejected by contractors for a variety of reasons including: incorrect billing information, terminated provider, the beneficiary is not eligible for Medicare or the claim was sent to the wrong contractor.  If a provider has questions about a claim rejected by a Medicare Fiscal Intermediary, Carrier or Administrative Contractor, the provider should contact the contractor directly.  It is never appropriate to direct the beneficiary who received the service billed on the claim to the 1-800-Medicare toll free line to resolve a claim rejection. [return to top]

Free Online CME Program Offered: Late Effects of Cancer Treatment and Survivorship

Anthem Blue Cross and Blue Shield and UCLA are offering a FREE Online Continuing Medical Education (CME) program that is designed to meet the needs of clinicians who care for individuals with cancer or who have survived cancer.

“Late Effects of Cancer Treatment and Survivorship: Strategies for Primary Care and Oncology Care Providers”

This is a FREE ONLINE CME Program
To access the Online Program, go to:

The program will provide 3 AMA PRA category 1 credits & continuing education for nurses*

Program goal:  To promote provider understanding regarding late effects of cancer treatment and survivorship and their role in long-term surveillance in order to reduce adverse health outcomes of cancer survivors. 
Data has shown that many Primary Care Physicians (PCPs) do not feel prepared to monitor and manage the late health effects that may arise with patients following cancer treatment.  A PCP’s sense of being prepared to handle transitional care issues for cancer survivors increases as the frequency of receiving detailed treatment information from oncologists increases.  We encourage oncology practitioners to utilize End of Treatment summaries, similar to the example provided toward the end of this program.

Course Directors:

  • Patricia Ganz, MD, Professor of Health Services and Medicine, David Geffen School of Medicine at UCLA and UCLA School of Public Health
  • Lisa Diller, MD, Clinical Director of Pediatric Oncology, Dana Farber Cancer Institute; Associate Professor of Pediatrics, Harvard Medical School, Department of Pediatric Oncology
  • Betty Ferrell, RN, PhD, FAAN, Research Scientist, City of Hope National Medical Center

Educational Objectives:

  • Describe national trends and information related to late effects of cancer treatment and survivorship for pediatric and adult populations.
  •  Assess survivorship medical and psychosocial issues.
  • Recognize providers’ role/opportunity in monitoring and managing pediatric and adult patients’ late effects.
  • Understand long-term follow-up guidelines that provide recommendations for screening and management of late effects that may potentially arise as a result of therapeutic exposures used during cancer.
  • Manage strategies/issues surrounding transition of care to primary care after discharge from cancer treatment.
  • Understand the importance of communication between primary care and oncology care providers and potential barriers such as socioeconomic disparities.

The program must be completed by September 15, 2007.   An extension through September 15, 2008 is currently under consideration.   Please contact Lynn Stillman at 603.695.7848 with any questions.

* Nursing Attendees: When completing the renewal form or the online CE section, under the section labeled "Provider Number," you will need to enter CME Category 1, instead of a BRN Provider Number.
This activity is endorsed by the Northern California Cancer Center.
Late Effects of Cancer Treatment and Survivorship: Strategies for Primary Care and Oncology Care Providers is supported in part by educational grants from the following: American Cancer Society; Amgen Inc.; AstraZeneca; Anthem Blue Cross Blue Cross Blue Shield of Georgia; Blue Cross of California; Bristol-Myers Squibb Company; Genentech, Inc.; John Wayne Cancer Foundation; Lance Armstrong Foundation; Merck and Co., Inc.; Pharmion Corporation; Sanofi-Aventis; and the WellPoint Foundation.
  [return to top]

"Collaboration Skills for Healthcare Professionals" Offered Friday, September 7, 2007

MMA's popular "First Fridays" CME offerings will continue in September with a program entitled, "Collaboration Skills for Healthcare Professionals."  The program will be held on Friday, Sept. 7, 2007 from 9:00 am to noon at the offices of the Maine Medical Association in Manchester.  There is a $60 fee which includes all course materials and a light breakfast.

The program will be presented by Beth Boynton, RN, MS, who is an organizational development consultant who has worked with many health care organizations in Maine.  Beth has twenty years experience as an RN in consulting, management, or direct care positions and more than ten years as a Nurse Consultant to business and industry for workers compensation and employee heatlh issues.  She also served as Adjunct Faculty for both the New England Healthcare Administration Program and Antioch New England Graduate School's Certificate in Healthcare Management program.

For further information or registration materials, visit the MMA website at or call Gail Begin at 622-3374 ext. 210.  [return to top]

MMA and MDI Hospital Present CME Program on "Medical Responses to a Mass Casualty" Sept. 6

MMA and Mount Desert Island Hospital are pleased to announce a program in connection with the MMA Annual Session entitled, "Medical Reponses to a Mass Casualty Incident in Maine" on Sept. 6, 2007 in Bar Harbor.  The program is being held a day prior to the MMA Annual Session at the same location which is the Harborside Hotel and Marina.  The program will run from 9:30 am to 4:30 pm and is, in part, funded through a grant from the Maine CDC.  Six hours of category 1 CME is available. 

There is a $40 fee which includes lunch and all course materials.   A registration form will be included as an insert in the July/August issue of Maine Medicine.  For more information, please contact Melanie Modine at MDI Hospital at 288-5082 ext. 444.

Objectives for the course include:

  • Understand the challenges of caring for multiple trauma victims, especially in a small health care system.
  • Understand how to utilize state emergency assistance and legally use outside providers to assist.
  • Be able to develop practical strategies for coping with a public health or mass casualty disaster, both advance planning and when one occurs.

Speakers include Col. Robert McAleer, USMC-Ret., Director of the Maine Emergency Management Agency.  [return to top]

Update: Dissemination of Data from the National Plan and Provider Enumeration System (NPPES) to Begin September 4, 2007

NPPES health care provider data that are disclosable under the Freedom of Information Act (FOIA) will be disclosed to the public by the Centers for Medicare & Medicaid Services (CMS).  In accordance with the e-FOIA Amendments, CMS will be disclosing these data via the Internet.  Data will be available in two forms:


  1. A query-only database, known as the NPI Registry.


  2. A downloadable file.


CMS is extending the period of time in which enumerated health care providers can view their FOIA-disclosable NPPES data and make any edits they feel are necessary prior to our initial disclosure of the data. 


We must build in time to resolve any errors or problems that may be encountered with edits that health care providers submit.  Therefore, in order to ensure edits are reflected in the NPI Registry when it first becomes operational and in the first downloadable file, health care providers need to submit their edits no later than Monday, August 20, 2007.  Health care providers who submit edits on paper need to ensure that they are mailed in time for receipt by the NPI Enumerator by that date. 


CMS will be making FOIA-disclosable NPPES health care provider data available beginning Tuesday, September 4, 2007.  The NPI Registry will become operational on September 4 and the downloadable file will be ready approximately one week later. 


Health care providers should refer to the document entitled, “Information on FOIA-Disclosable Data Elements in NPPES,” dated June 20, 2007 (found on the CMS NPI web page at ) for assistance in making their edits. Some of the key data elements that are FOIA-Disclosable are:

  • NPI


  • Entity Type Code (1-Individual or 2-Organization)


  • Replacement NPI


  • Provider Name (First Name, Middle Name, Last Name, Prefix, Suffix, Credential(s), OR the Legal Business Name for Organizations)


  • Provider Other Name (First Name, Middle Name, Last Name, OR ‘Doing Business As’ Name, Former Legal Business Name, Other Name. for Organizations)


  • Provider Business Mailing Address (First line address, Second line address, City, State, Postal Code, and Country Code if outside U.S., Telephone Number, Fax Number)


  • Provider Business Location Address (First line address, Second line address, City, State, Postal Code, and Country Code if outside U.S., Telephone Number, Fax Number)


  • Healthcare Provider Taxonomy Code(s)


  • Other Provider Identifier(s)


  • Other Provider Identifier Type Code


  • Provider Enumeration Date


  • Last Update Date


  • NPI Deactivation Reason Code


  • NPI Deactivation Date


  • NPI Reactivation Date


  • Provider Gender Code


  • Provider License Number


  • Provider License Number State Code


  • Authorized Official Contact Information (First Name, Middle Name, Last Name, Title or Position, Telephone Number)


The delay in the dissemination of NPPES data does not alter the requirement that HIPAA covered entities must comply with the requirements of the NPI Final Rule no later than May 23, 2008.  All NPI contingencies that may be in place must be lifted by that date.


Not sure what an NPI is and how you can get it, share it and use it?  As always, more information and education on the NPI can be found through the CMS NPI page on the CMS website.  Providers can apply for an NPI online at or can call the NPI enumerator to request a paper application at 1-800-465-3203 [return to top]

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