July 21, 2008

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Highlights of the Medicare Improvements for Patients & Providers Act of 2008

As reported by the MMA in a legislative alert last week, the U.S. Congress overrode President Bush's veto of H.R. 6331, the Medicare Improvements for Patients & Providers Act of 2008 by wide margins - 383-41 in the House and 70-26 in the Senate.  All four members of Maine's Congressional delegation voted to override, thereby continuing their long-standing support for the physician community on the Medicare SGR issue.  Most importantly, the bill prevents a 10.6% Medicare payment cut scheduled to take effect on July 1, 2008, replaces it with a payment freeze for the rest of 2008, and provides a 1.1% pay increase for 2009.  However, the bill includes a number of other policy changes outlined below.

The following are highlights of H.R. 6331 provided by analysts at the AMA.

  • Provides 18-month Medicare physician payment fix, stopping the 10.6% cut on July 1, 2008, and the 5.4% cut on January 1, 2009, extending the June 2008 rates through December 31, 2008, and providing an additional 1.1% update for 2009.
  • According to CBO cost estimates, a 1% update for 2009 funded in a way that produces no budgetary effects after 2009 would lead to a 21% cut in January 2010.  It establishes a Medicare Improvement Fund and deposits $19.9 billion for use in 2014-17.
  • Requires that budget neutrality adjustments for 2007 and 2008 relative value changes be applied to the conversion factor, instead of work relative values, effective in 2009.
  • Extends work GPCI floor through 2009 and provides a 1.5 work GPCI for Alaska starting in 2009.
  • Extends PQRI reporting for 2 years and provides a 2% bonus payment for reporting.
  • Adds new funding and expanded authority for the Medical Home Demonstration Project.
  • Provides a 5% pay increase for certain mental health services from July 1, 2008 through December 31, 2009.
  • Provides teaching anesthesiologists 100% payment for two concurrent cases starting in 2010.
  • Extends the exceptions process for therapy caps through December 31, 2009.
  • Allows independent laboratories to bill for pathology services furnished to hospital patients through 2009.
  • Permanently extends the accommodation for physicians ordered to active duty in the armed services so that they can engage in substitute billing arrangements for more than 60 days.
  • Delays Medicare durable medical equipment (DMEPOS) competitive bidding program for 18 months (offset with reduced DMEPOS payments).  Allows HHS to permanently exempt physician suppliers of DMEPOS from DME accreditation.
  • Increases asset limits for beneficiaries to qualify for Part D low-income subsidy.
  • Expands coverage of Medicare preventive services, including the "Welcome to Medicare" visit.
  • Provides Medicare coverage of cardiac and pulmonary rehabilitation services.
  • Phases in a reduction in co-pays for mental health to the same level as other outpatient services (20%).
  • Allows Part D coverage of benzodiazepines and barbiturates.
  • Provides the same standard for off-label drug coverage under Part D as under Part B.
  • Phases out double payment to Medicare Advantage (MA) plans for indirect medical education.
  • Establishes prohibited federal marketing practices and confers states with authority to regulate MA and Part D marketing abuses.  Prohibitions include no marketing activities in physician offices.
  • Eliminates the ability of MA provate fee-for-service (PFFS) plans to "deem" physicians where there are two or more MA HMO or PPO plans in an area, beginning in 2011.
  • Provides a 2% bonus in 2009 and 2010 for e-prescribing by eligible physicians, reduced to 1% in 2011 and 2012 and 0.5% in 2013.  If eligible physicians do not e-prescribe, imposes penalties of -1% in 2012, -1.5% in 2013, and -2% in 2014 and beyond.  Provides hardship exemptions.
  • Requires physicians and other suppliers that furnish advanced diagnostic impaging services (MRI, CT, and nuclear medicine/PET) to meet Medicare accreditation standards by January 1, 2012.
  • Extends the Federal Payment Levy program to Medicare providers.  This is an IRS program to collect revenues from federal contractors who fail to pay their taxes.

You can find more information about H.R. 6331 on the House Ways & Means Committee web site:  http://waysandmeans.house.gov/MoreInfo.asp?section=45.


Claims Processing Under the New Medicare Payment Rates

Medicare contractors currently are working to update their payment systems with the new rates from the Medicare Improvements for Patients & Providers Act of 2008 (H.R. 6331, now known as "MIPPA").  In the meantime, to avoid a disruption to the payment of claims for physicians, non-physician practitioners, and other providers of services paid under the MPFS, Medicare contractors will continue to process the claims that have been on hold on a rolling basis (first in/first out) for payment at the -10.6% update level.  After your local contractor begins to pay claims at the new 0.5% rate, to the extent possible, the contractor will begin to automatically reprocess any claims paid at the lower rates.

Under the Medicare statute, Medicare pays the lower of submitted charges or the Medicare fee schedule amount.  Claims with dates of service of July 1st and later billed with a submitted charge at least at the level of the January 1 - June 30, 2008 fee schedule amount will be automatically reprocessed.  Any lesser amounts will require providers to contact their local contractor for direction on obtaining adjustments.  Non-participating physicians who submitted unassigned claims at the reduced nonparticipation amount also will need to request an adjustment.

You will find more information about Medicare claims processing during this transition period on the CMS web site:  http://www.cms.hhs.gov/PhysicianFeeSched/[return to top]

Reserve Your Room this Week for Annual Session - Room Block Expires July 25

Members and guests planning to attend the Association's 155th Annual Session from September 4-7, 2008 at the Samoset Resort in Rockport are reminded to make their room reservations directly with the Samoset by calling 1-800-341-1650.  Be sure to mention that you are there for the MMA meeting.

Although there may be rooms available after the deadline, the room block expires on this coming Friday, July 25th so you would be wise to make your room reservation this week.  For attendees who wish to stay at alternate locations, a list of such facilities is available by contacting Diane McMahon at MMA at 622-3374, ext. 216 or via e-mail to dmcmahon@mainemed.com.

After making your room reservation, please be sure to register with MMA as well.

This year's meeting promises to be one of the best ever with an impressive list of speakers beginning with Elliott Fisher, M.D., MPH from Dartmouth Medical School who will speak on Thursday, September 4th at a Quality Symposium jointly sponsored by MMA and the Maine Hospital Association.

Associated meetings being held during the weekend include the Maine Society of Orthopedic Surgeons, the Maine Urological Association, the Maine Association of Psychiatric Physicians, the Aroostook County Medical Society, and the Kennebec County Medical Society. [return to top]

Lisa Letourneau, M.D., MPH Named Executive Director of Quality Counts

The Board of Directors of Quality Counts has announced the completion of its search for a new Executive Director and named Lisa M. Letourneau, M.D., MPH to the position.  Dr. Letourneau will serve on a part-time basis and the position is expected to be assisted by a full-time Associate Director to be hired as soon as feasible.  Dr. Letourneau will begin the position immediately.

Dr. Letourneau is a resident of Scarborough and until recently served as Director of Clinical Integration for MaineHealth.  She also was the Chair of Quality Counts and has resigned that position in becoming the Executive Director.  A new Chair is expected to be named at an upcoming Board meeting on July 30th.

Dr. Letourneau is a graduate of Brown University and continued her medical education at the Dartmouth-Brown Joint Program in Medicine, earning her M.D. degree in 1987.  She completed her residency and internship in  internal medicine at the Maine Medical Center.

Dr. Letourneau was one of the first three Hanley Fellows selected by the Daniel Hanley Center for Health Leadership.  Other past positions of leadership included Chair of MMA's Committee on Public Health.  She is also a Physician Advisor for the Maine Center for Public Health.

The MMA welcomes Lisa to this new role and looks forward to working with her as Quality Counts continues to serve its important mission in Maine. [return to top]

MMA Services Include Review of Employment Contracts

MMA members are reminded that one of the services that the Association provides to its members is a legal review of the terms of employment contracts.  The MMA charges a flat fee of $250 for the service which has been helpful to many residents and other physicians.

If you are presented with an employment contract that you would like to have reviewed by the MMA legal staff, contact Gordon Smith, Esq. at 622-3374, ext. 212 or via e-mail to gsmith@mainemed.com. [return to top]

CMS PQRI 2007 Payments & Reports to Physicians

On Friday, July 18, 2008, AMA President Michael D. Maves, M.D., M.B.A. sent the following memo to medical societies in the federation.

This week, CMS announced the distribution of 2007 Physician Quality Reporting Initiative (PQRI) incentive payments for those eligible physicians, physician group practices, and other professionals who satisfactorily reported.  Payments will be distributed electronically to the Tax ID Number (TIN).  Registration is not needed to receive incentive payments.  According to CMS, more than $36 million in bonus payments will be made to more than 56,700 eligible PQRI participants who satisfactorily reported quality information to Medicare under the 2007 PQRI.

 Physicians, physician group practices, and other PQRI eligible professionals should receive their payments by August 2008.  The average incentive amount for individual professionals is more than $600 and the average incentive payment for a physician group practice is more than $4700, with the largest payment to a physician group practice being more than $205,700.

Feedback reports for all eligible professionals who participated (regardless if successful) will be made available separately beginning on July 15, 2008.  Registration is required to access these reports (see below).  These PDF reports will include information on reporting rates, clinical performance, and incentives earned by individual professionals, with summary information on reporting success and incentives earned at the practice (TIN) level.  Feedback reports will not include claim-level detail.

Access to Feedback Reports 

To access feedback reports, individuals (those who do not reassign Medicare benefits to another party) and organizations (those who receive reassigned payments from an individual professional) must register in the Individuals Authorized Access to CMS Computer Services (IACS) system.  CMS encourages both individuals and organizations to register as soon as possible to allow for appropriate registration processing.  To access the IACS web site, please visit:  http://www.cms.hhs.gov/MMAHelp/07_IACS.asp.

For questions on how to register, access, or change your IACS account, please contact External User Service (EUS) at 866-484-8049 or for TTY, 866-523-4759.

For questions on the 2007 PQRI reports related to the quality measures listed or any discrepancies with the reports, please contact the QualityNet Help Desk at 866-288-8912 or qnetsupport@ifmc.sdps.org.

2007 PQRI Data

The AMA has reached out to CMS in an effort to glean additional information from the 2007 PQRI data set file to help improve physician quality measure design.  Further, the AMA would like to conduct a more detailed review of the data to better understand possible barriers and stimuli to physician reporting.  

Potential reasons why 2007 PQRI payment not received

  • Participating Medicare eligible professionals did not submit all of their claims to their Carrier of A/B MAC by February 29, 2008.
  • A physician was found by the Measure Applicability Validation Process (MAV) to have been eligible to report on three or more measures, but only reported on one or two.
  • If not eligible to report on three quality measures, the professional did not report on the one or two applicable measures at least 80% of the time.
  • A professional did not report on three applicable measures at least 80% of the time during the reporting period.
  • 2007 PQRI incentive payments are subject to a cap, which reduces the 1.5% bonus payment if physicians reported only relatively few measures or failed to report on at least three applicable measures 80% of the time during the reporting period.  According to CMS, the cap only applied to 700 professionals participating in the 2007 PQRI.

You can find more information about the PQRI program on the CMS web site at:  http://www.cms.hhs.gov/pqri/. [return to top]

MaineCare Announces Plan to Implement $8.3 M Fee Increase

As you may know, the 123rd Maine Legislature approved a $3 million state General Fund ($8.3 M with federal match) increase in the MaineCare physician fee schedule to take effect July 1, 2008.  Governor Baldacci included this, the second such fee increase during his administration, as part of his most recent biennial budget proposal based upon the recommendation of DHHS Commissioner Brenda Harvey and her staff.  DHHS originally estimated that the $8.3 M would enable the Department to increase MaineCare rates from 53% of Medicare rates to 61.7% of Medicare rates, but the Department's analysis now indicates that this amount will bring rates up to 56.4% of the 2008 Medicare fee schedule.  This amount also enables the Department to increase the Primary Care Case Management (PCCM) fee from $2.50 pmpm to $3.50 pmpm.  DHHS announced this last week.  

Because the Department must amend provisions of the MaineCare Benefits Manual (MCBM) by the legal process required by the Administrative Procedures Act (APA), the changes in the fee schedule will not take place until this fall.  However, the fee increase will be retroactive to July 1, 2008.  The Department plans to adjust the payments for the period from July 1, 2008 through the effective date of the rule changes without requiring you to rebill any claims.

OMS Director Tony Marple's letter of July 11, 2008 on this matter also says that the Department plans to recommend that the Governor include sufficient funds to increase the fee schedule to 61.7% of Medicare rates in his SFY 2010-2011 biennial budget proposal.  [return to top]

Provider Advisory Group Hears New Name for MaineCare Claims Management System

The Governor's MaineCare Provider Advisory Group, established several years ago when the MECMS issues first came to light, met most recently on Thursday, July 17, 2008.  In addition to giving an update on the current claims processing status and MECMS, the Department staff and consultants provided an update on aspects of the Unisys Fiscal Agent implementation.  The name of the new claims processing system is the Maine Integrated Health Management Solution (MIHMS).  Phase I of the implementation process is provider re-enrollment.  The Department is initiating design sessions and expects to complete this in mid-September.  Provider outreach then will begin.  DHHS staff are devoting substantial time to a plan to move away from the use of local codes as required by federal law.  CMS staff recently made a visit to Maine to review the Fiscal Agent implementation process and the Department now has an implementation checklist with which to check our progress.

As usual, the Group also received an update on the Interim Payment Recovery process.  Of $530.7 M in interim payments issued, the Department has worked with providers to recover $481 M, leaving a balance of $49.7 M as of the end of the fiscal year on June 30, 2008.  During the last year, the interim payment balance outstanding for the provider category including physicians was reduced 61% from approximately $10 M to $3.9 M.  This provider category still faces more than $6 M in unprocessed claims for a variety of reasons.  At the end of the fiscal year, the MMA staff has worked with several physicians and the staff leadership of the interim payment recovery effort to resolve issues with the recovery effort.  The MMA urges physician practices with outstanding interim payment balances not to ignore DHHS efforts to communicate about the matter.  If the Department does not hear from you, the first step it will take is to file a lien in the county Registry of Deeds in which you work and/or live, and next the Department will make a referral to Maine Revenue Services for further action.  The federal government requires the State to vigorously pursue these outstanding funds. [return to top]

DHHS OIG & CMS Enter First "Resolution Agreement" for HIPAA Privacy Violation

On July 17, 2008, the U.S. DHHS announced that it had entered into a "resolution agreement" with Providence Health & Services for potential violations of the HIPAA privacy and security rules.  Providence Health is a HIPAA covered entity based in Seattle that does business in the Pacific Northwest and California.  The allegations are that Providence Health left unsecure electronic media and laptops containing protected health information (PHI) between September 2005 and March 2006 and that those items were lost or stolen.  The agreement requires Providence Health to pay $100,000 as a sanction (but, apparently not a civil monetary penalty as provided by the enforcement rules) and a corrective action plan.  The corrective action plan requires the company to:

  • revise its policies and procedures concerning physical and technical safeguards governing off-site transport and storage of electronic media containing PHI, subject to Department approval;
  • train workforce members on the safeguards;
  • conduct audits and site visits of facilities; and
  • submit compliance reports to HHS for 3 years.

OCR and CMS have resolved more than 6700 cases of alleged violation of the privacy and security rules by requiring covered entities to make systemic changes to their privacy and security practices.  In this case, the entity's cooperation was cited as the reason the case could be resolved without a civil monetary penalty.  Providence Health operates 26 hospitals, physician clinics, and a health plan. [return to top]

MOA Announces Retirement of Jack Ginty & Hiring of New Executive Director

The Maine Osteopathic Association issued the following press release on Friday, July 18, 2008. 

Jack Ginty, Maine Osteopathic Association’s Executive Director, recently announced his retirement after fulfilling and exceeding his commitment to the MOA as its transitional Director.  While serving as the MOA’s Executive Director, Mr. Ginty was dedicated to making Maine a better place for osteopathic physicians to practice medicine, for healthcare workers to work, and for patients to receive care.  He has worked diligently in developing, supporting, and promoting the advancement of osteopathic medicine.  Mr. Ginty’s experience and accomplishments within the Maine healthcare system, his enthusiasm for challenges and change, and his personal goals have advanced the osteopathic philosophy and its dedication to patient care in the medical community throughout the state.  The osteopathic community in Maine, has over the years, been a major factor in the high quality of healthcare providers within the state.  Under Mr. Ginty’s direction, its medical philosophy and dedication to patient care have been enthusiastically received by Maine patients throughout the state.  

Angela Cole Westhoff has been recently hired as the new Executive Director of the Maine Osteopathic Association.  Ms. Westhoff holds a masters and a bachelor’s degree in communications from the University of Maine with concentrations in Health Communication and Public Relations.

Ms. Westhoff was the Executive Director of Healthy Androscoggin Community Coalition, a non-profit public health agency, for the past four years.  While at Healthy Androscoggin, Ms. Westhoff directed the day-to-day operations of the organization, served as media spokesperson and legislative advocate.  Some of her accomplishments included doubling the organization’s staff size and securing an additional $5.5 million in state and federal grant funding for community health promotion efforts.  Her areas of expertise are in community health promotion, social marketing, grant writing, coalition development, and public relations.

Ms. Westhoff was the former Director of the Healthy Maine Partnership at Bridgton Hospital and served as Assistant Director of the Teen and Young Adult Health Program at the Maine Center for Disease Control and Prevention.  She has also worked in the college career-counseling field while serving as the Premedical and Sciences Assistant Director at Bates College and the Health Professions Advisor at the University of Maine. Angela currently resides in Poland, Maine with her husband James and daughter Caroline.

The MOA Board is confident that this will be a smooth transition.  Ms. Westhoff takes the reigns on August 18, 2008.  Mr. Ginty will be working closely with Ms. Westhoff during the transitional period.  MOA President Douglas Jorgensen, D.O. stated, "We are extremely appreciative of Jack's efforts, and enthusiastically await this transition.  With Angela's experience and the foundation Jack helped set, our organization continues to grow as osteopathic medicine continues to positively influence millions of lives around Maine and the world."


  • D.O. s are one of the fastest growing segments of health care professionals in the United States.  At the current rate of growth, it is estimated that at least 100, 000 osteopathic physicians will be in active medical practice by the year 2020.

  • There are currently over 685 active Osteopathic Physicians in the State of Maine.

  • Presently there are 54,707 active Osteopathic Physicians across the United States

  • More than 64% of all D.O.s practice primary care in areas of family practice, internal medicine, obstetrics/gynecology, and pediatrics.

  • D.O.s represent 6% of the total U.S. physician population and 8% of all military physicians.

  • D.O.s represent 15% of physicians in small towns and rural areas

  • Each year more than 100 million patient visits are made to D.O.s

  • For more information about D.O.s and osteopathic medicine, visit the Maine Osteopathic Association’s web site at www.mainedo.org.

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