November 7, 2011

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CMS Issues Final 2012 Physician Payment Rule and Fee Schedule: 27.4 Percent Cut Possible

The final 2012 Medicare Physician Payment Rule and Physician Fee Schedule, which sets payment levels and other associated policies for next year, was recently released by CMS and announced a 27.4% reduction in overall Medicare payment if the sustainable growth rate (SGR) is not addressed by Congress before January 1, 2012.  While smaller than the 29% cut previously expected, the announced cut would be devastating to both patients and all health care professionals in Maine, which has a higher than average number of Medicare patients. 

Given the magnitude of the cut, some physicians may want to review their options for participation, nonparticipation or opting out of the Medicare program.  The AMA has a resource kit for physicians on the three available options which been updated and is available free of charge at  The kit includes a descriptive  guide to the options, a calculator to help determine the impact of changing from participation to nonparticipation status, a sample affidavit and private contract, sample letters to communicate changes to patients and, new this year, a frequently asked question resource.  The Medicare options web page also contains an archived webinar in which former AMA President Cecil Wilson, M.D. explained the participation options for 2011.

Communication with Maine's congressional delegation is also essential as time is running out to fix the problem prior to congress recessing for the holidays.

In a significant accomplishment for physicians, the AMA/Specialty Society Relative Value Scale Update Committee (RUC) persuaded CMS that the resources involved in hospital observation care visits and hospital inpatient visits are equivalent.  CMS also accepted 87 percent of the RUC’s 252 recommendations for the 2012 Medicare payment schedule for new and revised codes and those that had been considered potentially misvalued, and 75 percent of the RUC’s 290 recommendations for the 4th Five-Year Review.  

The RUC had recommended that CMS begin paying for telephone calls, anticoagulant management, team conferences, and patient education in 2012.  CMS did not announce any plans to consider payment for these services, but emphasized that the agency will continue to work with stakeholders to ensure that care coordination and primary care services are appropriately recognized.  CMS agreed with the AMA, RUC, and specialties that a re-review of 91 Evaluation and Management services would not be productive at this time.  

CMS has retracted the requirement for physicians to sign lab requisitions. The rule marks the final step in the agency’s retreat from this mandate, which began with postponing implementation from Jan. to April 2011 and then agreeing not to enforce it.

 CMS is increasing the relative values for the Medicare Annual Wellness Visit codes to recognize additional resources associated with adding a health risk assessment to the service’s requirements, but is continuing its policy of not covering a physical exam as part of these services.

Final 2011 First Friday Program on Dec. 2 Focuses on Supervising Mid-level Providers and Delegation

MMA concludes its 2011 educational programs on Friday morning, December 2nd when health lawyers, risk managers, regulators and physician assistants will discuss the requirements of supervising mid-level providers and the standards and risks associated with delegating medical tasks to medical assistants. Standards of practice will be addressed from the point of view of risk management, state regulations and payor requirements.  This three hour program will be available live and via webex.  The cost is $65 per person and the program will run from 9:00am to noon.

Watch your e-mail this week for a flyer on the program, which will also be included as an insert with the Fall issue of Maine Medicine.

Any questions about the program should be addressed to Gail Begin at MMA.  Gail can be reached at 622-3374 ext. 210 or via e-mail to  
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Shared Decision-Making Pilot Work Group Met this Morning

A ten person work group established to make recommendations to the Dirigo Health Agency on the goal and design features of a Maine-based Shared Decision-Making (SDM) pilot project met for the first time this morning at the offices of the Dirigo Health Agency in Augusta.  Two physicians are in the group, Robert Keller, M.D., who continues to chair the Maine Quality Forum Advisory Council, and Neil Korsen, M.D.of MaineHealth, who was involved with a previous study group established by the Maine Quality Forum.  That group submitted its final report to the Legislature in February of this year.  MMA EVP Gordon Smith also sits on the new work group.  The previous group included in its recommendations that a pilot project be instituted focusing on how primary care and specialty practices can advance the use of SDM.  It is hoped that the pilot will provide important lessons about clinical implementation and financial/system supports to help sustain the clinical service.

For the purposes of the group's work, the following definition of shared decision making is being utilized:

     Shared decision making happens when:

  • The patient is faced with two or more treatment options with no clear best choice in terms of survival, outcome, or functionality
  • The patient's own preferences and values drive decisions
  • The patient and clinician share information with each other, take steps to participate in the decision, and agree on a course of action based on the patient's preferences. 

The purpose of the Group is to review options and make recommendations with respect to:

  1. Core focus and goal(s) of the pilot.
  2. Target population(s) to be served by the pilot.
  3. Criteria for determining qualified applicants to participate as pilot sites.
  4. Working definition for shared decision-making that will be refined during the course of the pilot.
  5. Performance indicators for evaluating the pilot.
  6. Process for selecting pilot sites.
  7. Opportunities for external funding to support the pilot.
  8. Process for assuring quality oversight of the pilot.

The work group is to complete its work between now and April 2012.  The final work product will be a detailed concept paper for use in seeking external funding and in developing an RFP to send to qualified applicants.  These applicants could be a large employer group, a health plan, a large medical practice, or a health system.  The Dirigo Health Board is expected to eventually select up to five partnerships for the 18-month pilot which would operate from the Spring of 2012 to the Fall of 2013.

MMA members interested in this pilot should contact Gordon Smith for more information (

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Save the Date: MMA Legislative Committee Meeting, Dec. 6

Save the Date: MMA Legislative Committee Meeting 

Tuesday, December 6, 2011

6:30-8:30 p.m. 

MMA Headquarters, Association Drive, Manchester

All MMA members, specialty society leadership and legislative liaisons, and interested parties are welcome to join.  The Committee will discuss priorities for the second session of the legislature, MMA advocacy work related to the Affordable Care Act and Maine's health insurance reform law (Chapter 90) and organizational issues.  Dinner will be served. 

RSVP to Maureen Elwell, or (207) 622-3374x 219.


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Medicare eRx Payment Adjustment - November 1, 2011 Deadline Extended to Nov. 8

The Centers for Medicare & Medicaid Services (CMS) released the final regulation on the 2012 Medicare Electronic Prescribing Incentive (and penalty) Program on August 31, 2011. If you have not successfully e-prescribed and reported G8553 at least 10 times for applicable Medicare office visits between January 1, 2011 and June 30, 2011, you should apply immediately for an exemption or face a penalty.

The penalty for not successfully participating in the e-prescribing program or for not filing for an exemption by November 8, 2011 is a 1% payment reduction for all Medicare claims based on the 2012 fee schedule amounts. The penalty increases to 1.5% in 2013 and 2% in 2014.

The final regulation identifies the exemption categories to avoid the 2012 e-prescribing penalty. You can select one or more of the following exemptions that apply to your particular hardship situation:

  • Your practice is located in a rural area without high speed internet access.

  • Your practice is located in an area without sufficient available pharmacies for e-prescribing

  • You are registered to participate in the Medicare or Medicaid electronic health record (EHR) Incentive Program and you adopted Certified EHR Technology by October 1, 2011 and prior to the time you request an exemption.

  • You are unable to electronically prescribe due to local, State or Federal law or regulation (CMS clarified that physicians who mainly prescribe narcotics but due to certain limitations cannot submit these prescriptions electronically can apply for this exemption category).

  • Limited prescribing (You do not prescribe on a regular basis).

  • There were too few opportunities to report the e-prescribing measure due to limitations of the measure's denominator (You do e-prescribe but your e-prescriptions are not related to qualifying services/visits).

You must use the CMS on-line web-based tool to apply for the exemption(s). Application for exemptions can only be made online at: 

You will be asked for your TIN, NPI, business name (as enrolled in PECOS), and contact information. If your exemption claim is that you have enrolled in the Medicare and Medicaid EHR Incentive Program, you should also be prepared to give your registration ID and the ONC Certification number of your product.  You will also need to submit a 250 words or less justification for your hardship. If submitting more than one exemption request, have your statement reflect all of your exemption requests. Each hardship exemption must be submitted separately.

CMS has posted more information on the 2011 specifications at

See also the FAQs.

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Medicare RAC Program Improves

The Patient Protection and Affordable Care Act (ACA) directs states to enter into contracts with one or more recovery audit contractors (RACs) to identify overpayments and underpayments in the Medicaid program and recoup overpayments.  A Medicare RAC program has been in place since 2005 and expanded nationwide effective January 1, 2010.  States must implement the Medicaid RAC program by January 1, 2012. 

The final Medicaid RAC rule released by CMS in September 2011 includes many changes advocated by the AMA and physician groups, such as requiring RACs to hire a 1.0 FTE medical director who is an M.D. or D.O., requiring RACs to hire certified coders, requiring RACs to develop an education and outreach program for providers, limiting the look back period to three years, requiring RACs to return a contingency fee if an overpayment determination is reversed at any level of appeal, requiring states to coordinate RAC audits with other auditing entities and prohibiting RACs from auditing claims that have been or are currently being audited by another entity.  

CMS recently made several additional improvements to the program, including: a limit of 10 medical record requests in 45 days for offices of five or fewer physicians; a requirement that RACs complete complex coverage or coding reviews within 60 days or lose the contingency fee; an allowance of a discussion period wherein a request by a physician to speak with a Medical Director must be honored; and, a requirement that RAC websites list new audit issues by provider type.

While the final rule sets forth parameters for the qualifications and requirements of Medicaid RACs, CMS also affords states some flexibility in implementing the program.  Additional state-level advocacy may be necessary to further refine the program by limiting requests for exceptions to the final rule, shaping provisions where CMS has afforded states flexibility and implementing additional protections not covered in the final rule. 

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Medicare Covers Screening & Counseling for Alcohol Misuse and Screening for Depression

The Centers for Medicare & Medicaid Services (CMS) announced October 14th two new national coverage determinations that cover alcohol misuse screening and behavioral counseling for Medicare beneficiaries as well as screening for depression. These new coverage policies add to the existing portfolio of covered preventive services, most of which are now available to people with Medicare at no additional cost.

Annual alcohol misuse screening by primary care providers, such as a beneficiary’s family practice physician, internal medicine physician, or nurse practitioner, in settings such as physicians’ offices are covered under CMS’ new policies.  The benefit also includes four behavioral counseling sessions per year furnished by the primary care provider, if beneficiaries screen positive for alcohol misuse. 

Annual screening for depression for Medicare beneficiaries is now covered in primary care settings that have staff resources to follow up with appropriate treatment and referrals.  The purpose of  this screening is to assure accurate diagnosis, effective treatment and follow-up.

The coverage decision on alcohol misuse screening is online here and the decision on depression screening is available here.

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AMA Hosts Webinar on Final ACO Rule, Nov. 21

On October 20th, the Centers for Medicare & Medicaid Services (CMS) released its highly anticipated final blueprint for the Medicare accountable care organization (ACO) program. The AMA commented extensively on the proposed rule and CMS adopted many of its suggestions for encouraging physician led ACOs in the final rule, including the establishment of a new $170 million program to provide advance payments to physicians interested in forming a Medicare ACO. 

On November 21st at 7:00 p.m. ET, join AMA President-elect Jeremy Lazarus, MD, and national expert Harold Miller for a 60-minute webinar that will outline major provisions of the final rule, provide application information and timelines for the advanced payment and ACO programs, and answer physicians’ questions about ACOs and other payment innovations. 

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Week-long T.R. Reid Speaking Tour on Finding Better, Cheaper & Fairer Healthcare

Bestselling author, journalist, and NPR correspondent T.R. Reid is coming to Maine to talk about what we can all do to find and receive better, cheaper and fairer healthcare!  We encourage you to read his book, The Healing of America, and to join in the discussion by attending one of his public appearances around the state.  For more information, visit:

Monday, November 7th
University of Maine, Augusta *
Jewett Hall
7:00 PM - 8:30 PM 

Tuesday, November 8th
Husson University Business Breakfast *
Bangor, ME
8:00 AM - 9:00 AM
Email to sign up

Tuesday, November 8th
Portland Public Library *
Rines Auditorium
Portland, ME
5:30 PM - 6:30 PM

Wednesday, November 9th
Greater Portland Chamber Commerce
Eggs and Issues Business Breakfast
Portland, ME
7:30 AM - 8:30 AM

Thursday, November 10th
Androscoggin Chamber of Commerce Business Breakfast
Martindale Country Club Inc
Auburn, ME
7:15 AM - 8:55 AM
Click HERE to register

Thursday, November 10th
MHMC Annual Symposium
Abromson Center, USM
Portland, ME
8:00 AM - 3:00 PM

* Denotes free programs

TR Reid's week-long visit to Maine is being sponsored by the Maine Health Management Coalition Foundation, the Daniel Hanley Center for Health Leadership and the Maine Health Access Foundation, with support from Aligning Forces for QualityMaine Medical AssociationMaine Osteopathic AssociationAARPMaine Quality Counts and the Maine Development Foundation.

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Free ACA & Maine Health Insurance Reform Law Webinar, Nov 18

The MMA is pleased to announce a series of free webinars covering health care reform updates. 

The Affordable Care Act and Maine's New Health Insurance Law (Chapter 90) 

Hear from MMA staff attorneys about important updates impacting Maine patients and physician practices from the national Affordable Care Act and Chapter 90, Maine's new health insurance law. 

November 18th, 12-1 pm 

The Medicare Wellness Visit

What practices need to know about billing and coding for the new Medicare Wellness visit.  Make sure your office is taking advantage of the opportunity to bill for this new service. 

December 16th, 12-1 pm 

Speaker: Laurie A. Desjardins, CPC, PCS

Laurie joined Baker Newman Noyes in 2006. She is a Senior Manager in the Healthcare Management Consulting Division specializing in revenue management including physician coding, provider based implementation, chargemaster analysis, fee schedule analysis, chart review, and coding and billing education.

For more information or to register for any of the sessions, contact Jessa Barnard, MMA Associate General Counsel, at or  207-622-3374 x 211 

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MMA Members Eligible for 25% Discount on MMS Online CME Opportunities

Members of the Maine Medical Associate are eligible to receive a 25% discount on all online CME courses offered by the Massachusetts Medical Society.  To view current Massachusetts Medical Society CME Offerings, go to

The following tutorial includes a step-by-step guide for MMA members who would like to participate in this program.  PDF MMA/MMS Online CME Tutorial Guide

Important Information

  • The MMA discount educational voucher code is MMACME11.
  • If you have any questions about the registration or log in process, please contact the MMS Continuing Education Department at (800) 322-2303, ext 7306 or
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Upcoming Events & Conferences

Fall is conference season!  Take advantage of the many upcoming learning opportunities, including: 

Drugs, HIPAA & Safety Concerns

Wednesday, November 9, 2011 ~ 12:30 p.m - 4:00 p.m. 

Maine Medical Center, Dana Health Education Center, Portland, Maine 

Hospital health care providers and hospital security staff may be faced with issues related to contraband substances brought to the hospital with the patient.  In this session participates will learn about common drugs and the legal responsibilities when caring for the addicted patient. 

$10 registration fee (non MMC staff). CME Credit & Contact Hours available. 

For more information or to register, contact:  Beth Turner at (207) 622-2734 or 


2011 Infectious Disease Conference 

Tuesday, November 15, 2011 ~ 8:30 a.m. - 4:00 p.m. 

Augusta Civic Center, Augusta, Maine 

Since 1983, the Maine Center for Disease Control and Prevention, Division of Infectious Disease, Department of Health and Human Services has organized an annual infectious disease conference targeting public health issues of emerging concern to medical practitioners throughout the State.

For more information, or to register, click here


Chemicals and Our Health: Consumer Choices & Policy Decisions 

Tuesday, November 15, 2011 ~ 7:00 p.m. - 8:00 p.m. 

Central Maine Medical Center, Conference Room B, 12 High Street, Lewiston, Maine 

The Patrick Dempsey Center for Cancer Hope and Healing is pleased to announce a joint presentation with the Environmental Health Strategy Center on toxic chemicals and their impact on human health. What are some choices we can make as consumers to avoid toxic chemical exposure? When is toxic chemical exposure out of our control, and what policies do we need to enact in order to protect our health? Each of our panelists, including a parent, health professional, and policy advocate, will offer insights on this challenging public health issue.  The event is free to attend. 

To Register: (207) 795-8250 or 

Maine Medical Group Management Association Half Day Educational Session 

Wednesday, November 30, 2011 ~ 8:00 a.m. - 12:00 p.m. 

Maine Medical Association, 30 Association Drive, Manchester, Maine or via Webex 

Collection Law presented by William Lund & Confidentiality in the Office presented by Medical Mutual 

$25 for MEMGMA members and $40 for all non-members

For for information, contact:

 Karen Wheeler at (207) 873-6173 or

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