December 26, 2011

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Congress Finally Passes Two-Month Delay in Medicare SGR Payment Cut

At the 11th hour, House Republicans in Congress agreed to support the two-month package delaying implementation of the Medicare payment (SGR) cut and extending the unemployment tax cut which had been passed by the Senate the previous week.  President Obama signed the legislation into law just prior to leaving Washington for the holidays.  Without the legislation, Maine physicians would have seen a reduction of 28.4% and 31.4% depending upon in which of the two Medicare payment zones the physician practices.

When Congress returns to Washington in January, it will be important for all of medicine to communicate the need for a long-term fix to the SGR problem.  It is expected that Congress will work on either a one-year or two-year delay.  Each physician in Maine should communicate with Maine's Congressional delegation as soon as possible and emphasize what this cut now scheduled for March 1, 2012 would mean to them and their patients.  Find contact information and a sample letter at the AMA Advocacy website.

You can find more information about the Medicare physician payment issue on the AMA's web site

The AMA also has some helpful guidance on Medicare participation options for physicians here.  

MMA Comments in Opposition to Rule 850 Changes

Maine's Bureau of Insurance (BOI) held a public hearing on December 20th concerning proposed amendments to the Bureau's Rule Chapter 850 on Health Plan Accountability.  One major purpose of the amendments was to reflect changes in underlying Maine law relating to health plan network adequacy standards enacted pursuant to Maine's new health insurance reform law (Chapter 90).   As summarized in previous issues of the Update, the proposed rules eliminate the current geographic network requirements including a maximum of 30 minutes travel time to primary care from an enrollee's residence and a maximum of 60 minute travel time to specialty care and hospital services.

The groups who spoke in support of the revisions included Anthem and the Maine Association of Health Plans.  The groups who spoke in opposition included the Maine Hospital Association, the Maine Medical Association, Consumers for Affordable Health Care, the Downeast Association of Physician Assistants (DEAPA) and the American Physical Therapy Association.  Gordon Smith, Esq., MMA Executive Vice President, testified on behalf of the MMA and also offered comments on behalf of DEAPA.

Among the groups who spoke in opposition, some of the major concerns were:

    • No guidance in defining “reasonable access” to services, instead this is left to the carriers to define
    • The proposed  rule does not comply with the intent of Legislature; the Senate record, in particular, clearly states that people cannot be forced to travel to obtain care, that incentives to travel for care must be positive (added value in the form of lower cost sharing or travel reimbursement) and not negative (penalties) - this is not reflected in the rule 
    • Senator Bartlett’s concern that a local community based provider can be eliminated from the carrier's network is not addressed; carriers would be able to decide what their networks will look like and justify their decision without any guidance from the BOI
    • The elimination of the requirements to provide access to providers that treat people with “special needs” and to provide access to “essential community providers” 
    • The removal of the requirement that plans file information related to the ratio of specialty providers to enrollees

      The Maine Medical Association is currently preparing written comments to submit by the BOI's January 6th deadline.  The MMA seeks feedback from physician practices regarding the impact of these changes, especially on rural specialty practices.  Please send any comments to Jessa Barnard at  The proposed rule changes can be found here:

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      L.D. 1501 Work Group Completes Report on Reducing Prescription Drug Abuse and Addiction

      The work group established  by L.D. 1501 has completed its report to the Legislature.

      There was a final consensus around a number of important issues, as follows:

      1. Participating in the state's Prescription Monitoring Program (PMP) will be strongly encouraged, but not mandated.
      2. Appropriate continuing education courses will be developed but any mandated education will likely come from  the federal level, not because of any state mandate.
      3. Prescribers will be encouraged to exercise universal precautions when starting a patient on opioid therapy for chronic pain.
      4. Prescribers will be provided with appropriate assessment, screening and risk reduction tools.
      5. The licensing boards for the various prescribers will be asked to review the current rule, Chapter 21, regarding guidelines for treatment of chronic pain and adopt any necessary changes. 
      6. A number of enhancements to the PMP are recommended, all aimed at making the program more valuable to physicians and other prescribers.  Additional access to the program by law enforcement is also being considered.  
      7. Local law enforcement agencies will be encouraged to provide diversion alerts to local health professionals.  These alerts would contain photos and names of individuals arrested for drug related offenses. 
      8. In order to decrease the number of deaths due to accidental overdose, a pilot project to provide naloxone kits will be recommended along with appropriate state legislation providing for protection of individuals who prescribe, dispense or otherwise intervene.

      A copy of the final report will be placed on the MMA website,, later this week.  Any questions about the report should be addressed to Gordon Smith, Esq., MMA EVP who represented MMA on the work group, along with several physicians: or 622-3374 x212. [return to top]

      Eastern Maine Healthcare Systems Approved as Pioneer Accountable Care Organization

      Last Monday, Medicare officials announced that Eastern Maine Healthcare Systems in Bangor would be one of 32 networks across the nation selected to participate as a Pioneer Accountable Care Organization (ACO).  The system will be eligible to receive a portion of any shared savings associated with the program's operation in the EMHS service area.  Approximately 8,000 Medicare patients associated with EMHS, the Aroostook Medical Center in Presque Isle and Inland Hospital in Waterville will initially be included in the program.

      M. Michelle Hood, President and CEO of EMHS stated that, "I  hope patients see much less fragmentation in care and much more organization and coordination around their specific needs."

      The EMHS program will be the only Pioneer ACO operating in Maine.


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      MaineCare's MIHMS System Receives Federal Certification

      DHHS announced last week that the federal government had certified the state's Medicaid claims system (Maine Integrated Health Management Solution) as compliant with federal requirements.  The system, built by Molina, has processed claims since September, 2010 but was still awaiting federal certification.  Maine has not had a certified system since 2005 when the previous system (MECMS) failed. 

      The federal certification means that Maine Medicaid claims will be reimbursed by the federal government at 75%, rather than the 50% that has been the payment rate in recent times. The increased federal payment will be retroactive to September 1, 2010. 

      The Provider Advisory Committee, established when the claims management system failed in 2005, continues to meet once a month to review problems with claims management.  MMA representatives regularly attend these meetings which are open to the public.

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      Critical Access Hospital in Central Maine Area Seeks Physician VPMA

      A twenty-five bed, federally designated critical access hospital is seeking a physician interested in serving as its Vice President for Medical Affairs.  A limited clinical practice could also be part of the package.  Any physician interested in this opportunity may contact Gordon Smith, Esq., EVP of MMA who will pass the name on to the institution.  They may call Mr. Smith at 622-3374 ext. 212 or communicate via e-mail to [return to top]

      Affordable Care Act Implementation Updates

      Heading into 2012, implementation of the national health care reform law, the Affordable Care Act (ACA), continues to move forward at the state and national levels.  Below are some recent updates. 


      Under the ACA, each state is expected to have an exchange, or insurance marketplace, up and running by 2014.  In Maine, an Advisory Committee met over the early fall and made recommendations regarding what an exchange in this state should look like.  The legislature's Insurance and Financial Services (IFS) Committee has had several sessions this fall to consider the Advisory Committee's recommendations, which can be found here  When the legislature reconvenes in January, IFS will consider three bills creating an exchange: two carry-over bills plus a draft provided by the Advisory Committee.  IFS is scheduled to discuss the proposals on January 4th. 

      Essential Health Benefits

      The ACA requires that health plans offered in the individual and small group markets, both inside and outside of the insurance exchanges, offer a comprehensive package of items and services, known as “essential health benefits.”  Essential health benefits must include items and services within at least ten categories, such as maternity and newborn care, prescription drugs and preventive and wellness services. 

      The federal Department of Health & Human Services recently issued a bulletin outlining proposed guidance on how the essential health benefits would be defined:  It was expected that the federal government would define a standard benefit for the whole country; instead they announced that states would have the flexibility to select a benchmark plan that reflects the scope of services offered by a “typical employer plan" in the state.  The MMA is currently analyzing what this would mean for Maine. 

      Medicare Preventive Benefits 

      The Centers for Medicare & Medicaid Services recently released data on the use of Medicare's new no-cost preventive benefits, including an annual wellness visit and other screening services.  To date, 11.6% of Medicare beneficiaries in Maine have received an annual wellness visit and 68.1% have accessed other free services.   Maine ranks 4th in the number of beneficiaries receiving a wellness visit, behind only Connecticut (13.4%), Massachusetts (14.1%) and Rhode Island (16.1%).   The Maine Medical Association encourages practices to ensure they are taking advantage of billing for these new services and making them available to their patients.  For MMA materials available to assist your practice in billing and coding for Medicare preventive benefits, contact Jessa Barnard, 622-3374 x 211 or  For the full CMS release on use of preventive benefits, see

      Supreme Court Hearing

      On December 19th, the US Supreme Court released its schedule for oral arguments in the case challenging the ACA.  The Supreme Court will hear oral argument on four issues, including the controversial individual mandate and the constitutionality of the ACA's Medicaid expansion.  Oral argument will take place over three days in late March.  On March 26, the Court will hear one hour of arguments on whether challenges to the individual mandate are barred by the federal Anti-Injunction Act.  On March 27th, two hours of arguments will be permitted on the constitutionality of the individual mandate.  Finally, on March 28th, the Court will hear arguments on the remaining two issues:  90 minutes on whether other parts of the ACA can be upheld if the individual mandate is found to be unconstitutional, and one hour on the constitutionality of the Medicaid expansion.

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      Maine's Universal Vaccine Program Set to Begin 1/1/12

      The Maine Vaccine Board announced December 15th that all is in order to begin universal vaccine distribution for use beginning January 1, 2012.   The Universal Childhood Immunization Program was established in 2009 by Public Law 595 to provide all children from birth until 19 years of age in the State with access to a uniform set of vaccines funded by an assessment on health insurance carriers. 

      The Board reported that assessments are in line with what was expected and will be able to provide the estimated number of vaccines needed to cover all Maine children.  They also reported that ImmPact2 (the State's immunization registry) has been updated to allow practices to choose the vaccine brands and preparations provided through the Universal Immunization Program, and annual ImmPact contracts for 2012 have been distributed to practice sites. 

      In order to prepare, the Board recommends that practices: 

      • assure vaccines are on your facility's formulary

      • decide which vaccines you will use and which schedule will be your norm

      • sign and return the ImmPact contract

      • order vaccines for 1/1/12 use - new vaccines (PediaRix, KinRix, RotaRix, Menveo) can be used for ALL Children 

      The Board also announced the creation of a Provider Loss Mitigation Program.  This is a one-time program to compensate practices for claims denied by third-party payors after January 1st for remaining privately purchased vaccine supply.  Practices will receive payment for reported doses at the CDC contract price.  More information about the loss mitigation program will be disseminated as it become available.  Watch the Board website at: 

      In other vaccination news, Dr. Logan Murray of Maine Medical Center and Winthrop Pediatrics was awarded a 2012 Pfizer ASPIRE Junior Investigator Award in Pediatric Vaccine Research.  He will use the one-year, $40,000 grant to test the effect of a web-based vaccine education toolkit on the knowledge, attitudes, and behaviors of parents regarding immunizing their children.  The toolkit will be used by frontline clinical staff (nurses, MAs etc.), enabling them to provide vaccine-related information and answer parental questions.    

      Dr. Christopher Pezzullo, a pediatrician and chief medical officer at University Health Care and assistant professor of pediatrics at University of New England College of Osteopathic Medicine, was awarded an American Academy of Pediatrics Community Access to Child Health (CATCH) planning grant to explore ways to improve access to immunizations and health screenings for children in Cumberland County.  

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      Maine Legislature Reconvenes January 4th; MMA Invites Physicians to Serve as "Doctor of the Day"

      The 186 members of the 125th Maine Legislature will reconvene for their Second Regular Session on Wednesday, January 4, 2012 for a "short" session that is expected to end in mid-April.  The Department of Health and Human Services budget shortfall will be a substantial piece of business upon their return to the State House.  The legislature also will address bills carried over from the First Regular Session and some "emergency" bills admitted by vote of the Legislative Council, the 10 members comprising the legislative leadership.  

      The MMA needs physicians to serve as "Doctor of the Day" for this session.  In particular, we are looking for physicians able to serve on January 17, 24 & 31, as well as February 2.  The session begins at 10:00 a.m. on each of these days and you would likely be finished by noon.  FMI, contact Maureen Elwell, Legislative Assistant, at 622-3374, ext. 219 or, or see the MMA web site at:

      Also, please mark your calendars that the first weekly conference call of the MMA Legislative Committee will take place at 8:00 p.m. on Tuesday, January 10, 2012.  Look for more information on this call in the Maine Medicine Weekly Update of Monday, January 9th.

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      MMA Public Health Committee Announces 2012 Meeting Dates

      The Maine Medical Association Public Health Committee held its last regular meeting of the year last Wednesday, December 14th.  The Committee discussed a response to the Governor's proposed supplemental budget, the upcoming legislative session and how to support MMA President Dr. Nancy Cumming's physician wellness initiative. Other topics of discussion included: 

      • how best to support the work of the Maine CDC 
      • reform of the federal Toxic Substances Control Act 
      • emerging public health concerns such as exposure to particulate matter from wood smoke 

      The Committee also set its meeting schedule for 2012: 

      February 8th

      April 11th

      June 13th

      August 8th

      October 10th

      December 12th

      All meetings take place from 4-6 pm at the MMA Headquarters in Manchester.  There is always an option to join by phone. 

      Any physician interested in joining for all or some of the Committee activities should contact Jessa Barnard at or 622-3374 x211. 

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      Downeast Association of Physician Assistants Winter CME Meeting is Open for Registration

      22nd Annual Downeast Association of Physician Assistants

      Winter CME Conference

      February 1-4, 2012

      Grand Summit Resort Hotel & Conference Center

      Sunday River, Newry Maine

      This conference offers a wide range of topics for all PAs!

                       Register before the Early Bird Special expires 12/31/11


      Visit for all hotel, skiing/winter activities and directions!

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      Update on January 1, 2012 HIPAA 5010 Compliance Deadline

      January 1, 2012 marks the compliance deadline for use of the new version of the standard electronic Health Insurance Portability and Accountability (HIPAA) transactions.  Version 4010 has been in use since 2003 and the Centers for Medicare and Medicaid Services (CMS) is requiring all HIPAA "covered entities," which includes physicians who conduct any of the transactions named in HIPAA electronically (i.e. claims or remittance advice), to begin using Version 5010 starting on January 1, 2012. 

      The AMA has been extremely proactive in educating physicians and continues to make a wealth of easy to understand resources available for free on the AMA website at  Despite significant efforts by many in the health care industry, including physicians, there remains a considerable amount of work that needs to be done before everyone will be able to use the new standards.  For example, many practices have not had their practice management system (PMS) software upgraded by their vendor and have not been able to conduct testing with key trading partners. If your PMS vendor has not yet updated your system to accommodate the use of version 5010 you are strongly encouraged to contact them to obtain the necessary software upgrades.

      CMS Announces Enforcement Flexibility

      CMS is the federal agency charged with oversight of HIPAA standards.  AMA and others advocated to CMS that overall lack of industry readiness should not compromise physician cash flow following the January 1, 2012 compliance date. For this reason, CMS has indicated they will not levy any enforcement actions for the first three months of 2012 while HIPAA covered entities continue to work towards compliance.  What this means is that the HIPAA 5010 compliance date remains January 1, 2012 and all physicians and other HIPAA covered entities should continue to make every effort to comply with the use of the new standards, but that CMS will not take any enforcement action during this period.

      Medicare’s Plans

      Medicare, as the largest insurer that is required to comply with HIPAA requirements, has indicated that they are continuing to work with those who submit claims directly to them  (Submitters).  Submitters” include clearinghouses, third party billers, and physicians who submit claims directly (without the use of a third party or clearinghouse) to Medicare.  Every submitter is required to test with Medicare before claims can be processed using the 5010 format.  Medicare remains focused on ensuring all Submitters have tested successfully and that claims processing is not interrupted.  “What this means for physicians:

                  Direct Submitters

      If you are a physician who sends claims directly to Medicare (“Submitters”) without the use of a billing service or clearinghouse:

      • If you HAVE NOT tested by December  31, 2011: You are required to submit a "transition plan" to your Medicare contractor that details your plans for moving to 5010 and when you think you will be able to test with Medicare.  You will have 30 days to do this once you have been contacted by your Medicare contractor.
        • No prescribed format for transition plan:  It can be sent via letter, email, or fax and can be a brief explanation of your transition plans.   
        • Keep evidence plan was submitted: Submitters are strongly encouraged to retain evidence that a plan was sent (i.e. return receipt email, fax transmission confirmation, copy of an email).  
        • All submitters must test: Unless submitters have tested with their Medicare contractor, even if you submit compliant 5010 transactions, your claims will be rejected. 
      • If you HAVE tested successfully by December 31, 2011: You will be contacted by Medicare and told you have 30 days to move over to use of the 5010 standards.  Submitters that have not yet tested with Medicare prior to the compliance date will be contacted and asked to submit the transition plan described above. 

      Physicians who use a clearinghouse or billing service to submit their claims

      Physicians who rely on a billing service or clearinghouse to submit their claims to Medicare are NOT required to file a transition plan to Medicare.  The entity they use to submit their claims is the Submitter and is the one required to submit a transition plan.  These physicians should contact their billing services or clearinghouses to determine their ability to generate the physician’s claims and other transactions using the Version 5010 format.

      For More information

      For more information on 5010 please visit and

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      Office of MaineCare Services Reminds Practices to Test for HIPAA Version 5010

      Remember to Test for 5010!

      It’s the final push – the transition to HIPAA Version 5010 is around the corner! If your organization submits electronically in batches to MaineCare, you must complete certification testing via the MIHMS HealthPAS online portal.  Testing resources are available. Visit for background information, testing instructions, and Frequently Asked Questions about testing HIPAA Version 5010 transactions with MaineCare.

      If you currently submit HIPAA Version 4010 transactions electronically in batches, this applies to you. If you are a provider that uses a clearinghouse or billing agent, you do not need to test with MaineCare at this time. However, please verify that your clearinghouse or billing agent is completing HIPAA Version 5010 certification testing with MaineCare. The shift to HIPAA Version 5010 will not affect paper or Direct Data Entry (DDE) claims.

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