August 20, 2007

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Important Clarification on the Use of Medical Assistants in Hospital-Owned, Provider-based Practices

If your medical practice relies on the delegation by a physician of medical acts to unlicensed persons, such as medical assistants, please read the article below to understand the current legal status of such delegation.

MMA and MHA representatives met this week with representatives of the state's Division of Licensing and Regulatory Services to discuss the interpretation of the provision in the Medical Practice Act  (specifically Title 32, section 3270-A) which permits physicians to delegate medical acts to their own employees, where such acts have customarily been performed by medical assistants or other unlicensed personnel.  The Division had previously expressed concern about the current delegation provision as it relates to hospital-owned provider-based practices, as the delegation in those instances would be to the hospital's employees rather than to the physician's employees.  An interpretation that would result in a prohibition of such delegation could have resulted in a significant workforce problem in the affected  practices, as the use of medical assistants has become widespread.

As the result of the meeting, which was also attended by the Board of Medicine Executive Director and counsel, the Division has agreed not to issue citations of deficiency for physician delegation to unlicensed, uncertified staff in provider-based practices so long as there are job descriptions for such staff that describe the necessary education/training /competencies for the person and define the qualified supervisor who is responsible for the delegated acts.

The Division intends to meet again with the interested parties following more input from the Board of Licensure in Medicine (BOLM) and expressed a willingness to defer to the licensing boards on such a matter of interpretation.  The BOLM staff has not expressed concern about the delegation to employees to other than the physician's own employees, recognizing that the applicable statutory language was written well before the advent of hospital-owned practices. 

The meeting was attended by Andy MacLean and Gordon Smith, from MMA; Sandra Parker, MHA;  Denise Osgood, Division of Licensing and Regulatory Services; Randal Manning and Dennis Smith, Esq. from the Board of Licensure in Medicine,; Dan Washburn, Maine Primary Care Association, and Jack Ginty, Executive Director of the Maine Osteopathic Association.

Although the issue seems tentatively settled for the time being, MMA staff will continue to work with MHA staff, other interested parties and the state to determine if a change in the statutory language might be desirable, in order the clarify its intent.

MMA Seeks Volunteers for Committee

Any membership association is dependent upon volunteer leadership to grow and flourish.  MMA has several opportunities for physician members wishing to serve the association in some capacity.  We are looking for members willing to serve on one or more of the following committees:

  • Bylaws
  • Nominations
  • Public Health
  • Legislation
  • Membership and Member Benefits
  • Quality Improvement and Peer Review

There may also be Executive Committee vacancies in some counties, including specifically Oxford County, York County and Penobscot County.

We are also in need of two osteopathic representatives on the Committee on Physician Health.

Members interested in a committee appointment should contact the Association's Executive Vice President, Gordon Smith at [return to top]

MaineCare MECMS Update

The Governor's MaineCare Providers Advisory Group met on August 16 and heard updates from MaineCare staff on the MECMS issue and related matters.  Highlights of the Update included:

  • Receipt of the letter from CMS approving the Department's Planning Advance Planning Document for an accelerated procurement process for the replacement of the MECMS system
  • A description of the five patches in the existing system scheduled for August 29
  • Further instruction relative to the void functionality patch scheduled for Oct. 1, with provider training scheduled for later in October

The void functionality, as noted above, is scheduled for implementation to MeCMS in October.  A specific date will be give for providers to begin submission of new void transactions.  Instructs for using the functionality will be given and providers should not attempt to submit new voids in advance of receiving the billing instructions.

If a provider's claims are paying correctly today, then a void followed by a rebill should result in a proper payment.  However, there are no guarantees that a different issue won't arise when rebilling these claims.  Please be aware that, if claims are not paying correctly at this time due to issues such as inaccurate co-pays, certain limit problems, etc., those issues will not be corrected by implementation of the void functionality.  Detailed provider training on use of the void functionality will take place in early October.

Relative to the replacement of MeCMS, site visits will begin before the end of August in states selected by the four potential vendors, ACS, EDS, First Health and Unisys.  A new system is not expected to be operational prior to Jan. 2010.

Weekly metrics for the week ending August 12, 2997 showed that total claims for the week were 154, 873 of which 95.32 % were processed to pay or deny status.  Suspended claims inventory remains at 76,076.  In addition to suspended claims, there are unresolved claims in MeCMS with the status of edits processing failure and fund allocation failure.

The Group will meet again on August 31 in conjunction with the Technical Advisory Committee.  Brenda McCormick will attend that meeting to discuss the details of the new planned care initiaitve designed to save $100 million in the existing fiscal year.  When MMA staff last inquired, the proposed contract with the care management firm Schaller Anderson was still being negotiated. [return to top]

Gov. Baldacci Nominates Two to Dirigo Health Board

Governor John Baldacci has nominated two individuals to serve on the Dirigo Health Agency Board, replacing Dana Connors and Ned McCann.

The first appointee, Mary McAleney of South Portland, is recently retired from the U.S. Small Business Administration, where she had served as district director.  Previously, she had served an an aide to Democratic Senator George Michell.

The second nominee is Mary Anne Turowski of Newburgh who works as the legislative and political director for the Maine State Employees Association.  She previously worked 14 years for the Maine Department of Human Services.

"I am pleased to have two candidates of such high caliber to serve on this important board," Governor Baldacci said in a prepared statement.  "Mary And Mary Anne are highly respected across the state and will use their considerable expertise to move forward our important effort to bring affordable, quality health care to every man, woman and child in Maine."

The nominations are subject to confirmation by the State Senate which is expected to meet in September to handle these nominations and others. [return to top]

Welcome to Maine Medical Partners, Newest Members of MMA's Group Membership Program

MMA welcomes the physician members of Maine Medical Partners which voted unanimously last week to become members of the association through MMA's Group Membership Program.  Maine Medical Partners is the largest hospital-owned medical practice in the state and is affiliated with Maine Medical Center.  Over one hundred physicians are associated with the practices which include internal medicine, family practice, pediatrics, the pediatric specialty practices, the hospitalist practice, the Centers for Endocrinology & Diabetes, the Maine Children's Cancer Program, Neurosurgery and Spine Associates, Ob/Gyn, the Maine Center for Reproductive Health and Surgical Associates.

MMA's group membership program is available to any practice in the state with ten or more physicians.  Contact Lisa Martin or Gordon Smith at MMA if you are interested in knowing more about this program.  (; [return to top]

AMA Provides Update on CMS Guidance on Tamper-Resistant Prescriptions for Medicaid

CMS has now released guidance to State Medicaid Directors on the October 1, 2007 requirement for handwritten prescriptions to be written on tamper-resistant prescription pads in order to be covered by Medicaid, which is available at the following links: 

The AMA views the guidance as responsive to most of the recommendations that we received from state and specialty medical societies and transmitted to CMS last June, early in the CMS process.  For example, you will note that all current state requirements and standards are deemed to meet the new CMS standards, that states who provide the pads to physicians at no cost can treat the expenditure as a Medicaid administrative cost, that as long as the prescription is provided on either a tamper-resistant pad or faxed, phoned in within 72 hours of it being filled at the pharmacy it will be covered, and that the standards for the actual prescription pads are very flexible, with pads required to meet one of three standards by October 1, 2007 and not having to meet all the standards until October 1, 2008.  Finally, you will note that many prescriptions are exempt from the new requirements, including nursing home prescriptions, refills of prescriptions written before October 1, and phoned, faxed and electronic prescriptions.

We greatly appreciate the information that we received, particularly from state medical societies in states that currently have tamper-resistant prescription pad laws, and believe that CMS attempted to be as flexible as possible within its definition of its authority. Nonetheless, we remain extremely concerned about the implementation date for this new requirement just six weeks from now and we will continue advocating to the Administration and Congress on the need to delay the effective date.

Please note the following key elements of the guidance: 


  • Prescriptions provided in nursing facilities and certain other settings are exempt
  • Refills of written prescriptions presented at a pharmacy before Oct. 1 are exempt
  • Electronic, faxed and telephoned prescriptions are exempt
  • Prescriptions paid for by a managed care entity are exempt 


  • By Oct. 1, 2007, prescription pads must meet one of the following standards, and by Oct. 1, 2008 they must meet all three:
  • Features to prevent unauthorized copying
  • Features to prevent erasure or modification of the prescription
  • Features to prevent use of counterfeit prescription forms
  • All existing state laws and requirements for tamper-resistant prescriptions are deemed to meet or exceed the CMS standard. 

Emergencies:  Prescriptions will be covered as long as the physician provides the pharmacy with a verbal, faxed, electronic, or tamper-resistant written prescription within 72 hours of the date the prescription was filled. 

Costs:  States that purchase compliant prescription pads for Medicaid prescriptions and provide them to physicians at no cost or at a discounted rate may treat the cost as an administrative expense under Medicaid.

[return to top]

MMA & AMA Join Amicus Brief In U.S. Supreme Court Case on Sale of Tobacco Products Over the Internet

Recently, the MMA & the AMA have joined in an amicus brief prepared by the Tobacco Control Legal Consortium in a case entitled, Maine v. New Hampshire Motor Transport Association, a case involving federal preemption & the right of a state to regulate the sale of tobacco over the internet. 

The case follows the Maine legislature's 2003 enactment of a "tobacco delivery law" that regulates the sale of tobacco products, purchased over the internet or by phone, to ensure that these products do not reach minors & are not delivered by unlicensed tobacco retailers.  The U.S. Court of Appeals for the First Circuit in Boston ruled that the Maine law was preempted by the Federal Aviation Administration Authorization Act of 1994, but the Consortium brief argues that the First Circuit ruling is an overly broad interpretation of a federal statute that unreasonably restricts Maine and other states from regulating direct internet or phone sales of tobacco & controlling youth access to tobacco. [return to top]

Notice: Decision May Be Necessary in Second Settlement of Blue Cross Blue Shield Litigation

By now, many Maine physicians probably have received a Notice of Proposed Settlement in the class action litigation by physician organizations against the country's Blue Cross Blue Shield plans entitled, Rick Love, M.D. et al. v. Blue Cross and Blue Shield Association, et al.  If you provided covered services to any Blue plan member between May 22, 1999 & May 31, 2007, you are a member of the class covered by a Settlement Agreement reached on April 27, 2007.  THIS SETTLEMENT DOES NOT COVER ANTHEM/WELLPOINT, MAINE'S PRINCIPAL BCBS PLAN, WHICH REACHED A SEPARATE SETTLEMENT PREVIOUSLY.  However, Blue Cross Blue Shield of Massachusetts, Blue Cross Blue Shield of Rhode Island, & a number of BCBS plans in New York, New Jersey, & Pennsylvania are covered by the settlement, so if you submitted claims to these carriers during the covered period, you may participate in the settlement.

The settlement agreement includes injunctive relief against certain health plan practices including, but not limited to:

  • Misrepresenting and/or failing to disclose the use the use of edits to unilaterally "bundle," "downcode," and/or reject claims for medically necessary covered services;
  • Failing to pay for "medically necessary" services in accordance with member plan documents;
  • Failing and/or refusing to recognize CPT modifiers;
  • Concealing and/or misrepresenting the use of improper guidelines and criteria to deny, delay, and/or reduce payment for medically necessary covered services;
  • Misrepresenting and/or refusing to disclose applicable fee schedules; and
  • Failing to pay claims for medically necessary covered services within the required statutory and/or contractual time periods.

The settlement agreement also includes a Settlement Fund in the amount of $131,209,507, which together with accrued interest, will be distributed to physician class members who timely file a claim form in accordance with a methodology outlined in the settlement agreement.


Blue Parties' Settlement Administrator, P.O. Box 4349, Portland, OR 97208-4349


Blue Parties' Notice Administrator, P.O. Box 4349, Portland, OR 97208-4349

If you are a class member, the MMA recommends that you file a claim form to participate in the settlement.  It is unlikely that any Maine physician or medical practice is prepared to pursue unilateral action against these health plans and preserving that right is all you would accomplish by opting out of the settlement as described above.

You can find the claim form, notice form, & more information about this settlement on the internet at:

If you have further questions about this settlement, please contact Andrew MacLean, Deputy EVP, at or by phone at 622-3374, ext. 214.
[return to top]

Proportion of Physicians in Solo/Two-Physician Practices Drops

According to a national study conducted by the Center For Studying Health System Change (HSC), the proportion of physicians in solo and two-physician practices decreased immensely from 40.7% in 1996-97 to 32.5% in 2004-05.  Physicians do not appear to be moving to multispecialty practices. The proportion of physicians in multispecialty practices decreased from 30.9% to 27.5% between 1998-99 and 2004-05. The HSC study also indicated that while younger physicians were more likely than older physicians to practice in larger groups and to be non-owners, the gap narrowed between 1996-97 and 2004-05. The numbers of physicians 51 and older practicing in solo or two-physician practices declined 12.7%  between 1996-97 and 2004-05, from 51.5% to 38.8%. [return to top]

Support SCHIP Press Conference Held in Portland

A press conference organized by the Maine Children’s Alliance (MCA) and supported by the Robert Woods Johnson Foundation’s (RWJF) Cover the Uninsured campaign was held on August 13 at the Barbara Bush Children’s Hospital at Maine Medical Center.  Speakers included Governor Baldacci and State Senator Peter Mills, as well as Rick Kellerman, MD, President of the American Academy of Family Physicians (AAFP); John Bancroft, MD, MMC Chief of Pediatrics; Elinor Goldberg, President of MCA; David Morse, VP for Communications of RJWF and Tania Reid, mother of a SCHIP recipient.  Bills renewing the S-CHIP program for 5 years as well as possibly expanding coverage have been passed by both the U.S. House and Senate, but are awaiting reconciliation in early September and possible veto by President Bush.  The current program expires September 30th.  All four congressional delegates from Maine are in support.

Other members of the Family Medicine Community in attendance were:  Judy Chamberlain, MD, AAFP Board Member and AAFP President-Elect Candidate; Elisabeth Fowlie Mock, MD, MPH, Maine Academy of Family Physicians (MAFP) President-Elect; Deborah Halback, MAFP Executive Director and two members of the AAFP public relations staff.

While over 31,000 kids in Maine have been covered at some point by SCHIP, there are currently approximately 20,000 kids in Maine without health insurance.  Most of these kids are from families with at least one fulltime working parent.  Children without health insurance are twice as likely as kids with health insurance to miss out on medical care, including checkups.  More than one quarter of children without health insurance have not had any medical care in the past year, compared to 12 percent of children who are insured.  Nationally, the more than 9 million children without health insurance would more than fill every first and second grade desk in American classrooms.

The Maine Academy of Family Physicians, in conjunction with the American Academy of Family Physicians, continues to support opportunities, such as this, to influence public policy.  Should you be interested in participating in future activities, contact Deborah Halback at the MAFP office, 938-5005.

Data from: (Robert Woods Johnson Foundation) [return to top]

Update on Efforts to License Direct-Entry Midwives

Earlier today (Monday), the Department of Professional and Financial Regulation (DPFR) held its first public meeting on L.D. 1827 as part of the Sunrise Review being conducted at the request of the Legislature's Committee on Business, Research and Economic Development.  The Sunrise statute requires any group which is seeking licensure for the first time to answer a series of questions which are then subject to an independent evaluation by the Department.

In attendance today were several midwives and a representative of their national advocacy organization, the North American Registry of Midwives (NAROM).  MMA advocacy staff represented physician interests.  Also attending were representatives from the Board of Nursing.

DPFR staff reviewed fifteen additional questions that staff had following review of the previous materials.  Each member of the audience was able to respond to each question in a public session that lasted nearly four hours.  A key question that the staff kept coming back to was how the licensing of the non-nurse, direct-entry midwives would enhance the interests of public health and safety.  It was clear that the midwives are seeking the respect and prestige often associated with state licensure, but are not able to articulate how their proposal would advance the interests of the public.  For instance, the proposal they are advancing (L.D. 1827) would not prohibit midwives who do not achieve certification or licensure from practicing.  The issue of administering medication was also a major theme of the hearing.

MMA representatives continually expressed interest in helping to facilitate better communications between the midwives and the medical and nursing communities.  Executive Vice President Gordon Smith also expressed the view that legislation alone would not achieve the gain in status and prestige that the midwives were seeking.  "In fact, seeking credentials through legislation may set back the cause, by creating more alarm and resentment in the medical and nursing communities," noted Smith.  At the same time, Smith acknowledged that physicians need to learn more about the education and training of the direct-entry midwives.

Another meeting of the interested parties is likely to be held in late September, prior to the Department submitting its report to the Legislature. [return to top]

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