April 2, 2012

Subscribe to Maine Medicine eNewsletters
Manage Your Subscriptions
Email our Editor...
Maine Medical Association Home Page
. Search back issues
. Plain Text Version
Printer Friendly

CMS Announces Support for Maine's First Health Insurance CO-OP

On last Friday, the Centers for Medicaid & Medicare Services (CMS) announced support for the application of Maine Community Health Options under the CO-OP provision of the Affordable Care Act.  Maine Community Health Options was organized through the efforts of the Maine Primary Care Association, which represents the interests of Maine's Federally Qualified Health Centers.

With the announcement, Maine becomes one of several communities to benefit from the development of a non-profit health plan governed by a board consisting of a majority of consumers.  The announcement, which also included support for new CO-OPs in South Carolina and Oregon, bring to ten the number of Consumer Operated and Oriented Plans (CO-OP) designated.

Created in the Affordable Care Act, CO-OPs are intended to encourage innovative, consumer-responsive health insurers to compete with more traditional carriers in the individual and small business markets.  Beginning in 2014, CO-OPs will offer plans through the Insurance Exchange and in the open marketplace.

"CO-OPs will promote competition and increase choice in the health insurance market," said Marilyn Tavenner, CMS Acting Administrator.  These new private, non-profit insurers will be run by consumers and are designed to offer individuals and small businesses more affordable, consumer-friendly and high quality health insurance options.

For more information on the CO-OP program and recent awardees, click here.

POLITICAL PULSE: Legislative Highlights Including Consideration of New Opioid Proposal


As was announced in last week's Update, MaineCare officials are not moving forward with the opioid proposals included in the Supplemental Budget because of questions raised regarding legality of the proposals in the face of federal Medicaid law.  However, an alternative proposal has been presented to the Appropriations & Financial Services Committee and the Committee will determine whether to include it in the second supplemental budget the Committee is likely to finalize early this week.  The proposal was put together by MaineCare Medical Director Kevin Flanigan, M.D. and was developed with input from many physicians and physician groups.  The proposal is considered to be a significant improvement from the earlier proposal which imposed hard caps at 45 days for both patients with either acute or chronic pain.  

The proposal still would impose very strict limits in the case of acute pain (15 days for a first fill, then a prior authorization required for another 15 days, for a total limit of 30 days per calender year).  Each prescription would also require an office visit with the patient, although an alternative proposal is being considered for post-surgical patients.  In the case of new patients with chronic pain, patients would have to participate in one or more non-opioid interventions before an opiate would be paid for by MaineCare.  Once the patient qualifies for the medication, refills and further limits would be based upon the total amount of opioids allowed on a daily basis.

New patients who suffer from one of the several diagnoses known to have a typical poor response to opioids will require evaluation by a specialist before being authorized to receive an opioid prescription as part of their treatment plan.  There will need to be some adjustments in situations where there is not an available specialist.

With respect to the Prescription Monitoring Program, it is hoped that the program can be upgraded to push data out to the prescribers, particularly for the purpose of comparing their prescribing patterns with appropriate peer groups.

One of the significant remaining questions involves the treatment of existing MaineCare patients on opioid medication (some 60,000 patients).  One idea being considered is to convene a group of experts over the summer to work with Dr. Flanigan in developing a strategy for reducing opioid use in this population.

If you have questions or comments about these proposed  opioid limits, please contact MMA EVP Gordon Smith at gsmith@mainemed.com or 622-3374, ext. 212.  MaineCare members who have questions about this initiative can call the MaineCare Member Services help desk at: 1-800-977-6740.  Feel free to talk with legislators as well, as ultimately they will likely be faced very soon with a vote on these limits or something similar to them.  But the situation is very fluid given that the Attorney General's office will have to weigh in on whether any hard limits are legal.

In the meantime, the Appropriations Committee continues work on other aspects of the supplemental budget bill to address funding for 2012-2013.  The Health and Human Services Committee weighed in last week on Department of Health and Human Services budget items and a majority of that Committee supported a sweep of  $1.8 million from the Fund for a Healthy Maine and some restructuring of the General Assistance Program, though not the full cuts proposed by the Governor.  In addition, the Government Oversight Committee has agreed to launch an investigation into allegations by Democrats of a cover up in the computer issues at the Department of Health and Human Services leading to over 19,000 ineligible individuals receiving MaineCare services.  The Oversight Committee will be meeting tomorrow.

Budget documents can be found on the web here:  http://www.maine.gov/budget/budgetinfo/2012-13SecondSupplemental.htm.


As reported previously in the Update, the Maine Legislature has decided so far to not move forward with creating a state-based health insurance exchange.   If the state does not make substantial progress towards establishing an exchange by January 1, 2013, the federal government will establish one.  Instead, the Republican-supported bill that would have created an exchange has been modified to only regulate "navigators," or people who conduct outreach and education about the exchange and can help people enroll in the products offered through the exchange.  The MMA has concerns with the current proposal and believes it is in violation of final federal regulations on navigators.  For example, it only allows licensed insurance brokers who carry errors and omissions insurance to be navigators, while the federal regulations prohibit such requirements.  It is important that community non-profit groups are also allowed to serve as navigators in order to reach as many previously uninsured individuals as possible.  The bill is likely to be debated on the Senate floor tomorrow. 


The Health and Human Services Committee spent several days last week working LD 1887, a bill to carry out a Maine Department of Health & Human Services restructuring plan.  Under the proposal, the Offices of Substance Abuse and Adult Mental Health Services will merge to become the Office of Substance Abuse and Mental Health Services (SAMHS).  The Offices of Elder Services and Cognitive and Physical Disabilities Services will become the Office of Aging and Disability Services (OADS).  Finally, the Office of Child & Family Services will reorganize.  The Committee voted 9-3 in support of the restructuring after the proposal was modified to keep 17 intensive case managers who work with clients in county jails and  state prisons as state positions rather than contracting them out to private agencies.  The bill now moves to the full legislature. 


In a procedural move, L.D. 882, An Act to Limit Health Care Mandates died last week between the House and the Senate.  The bill stated that insurance companies cannot be required to offer plans that go beyond the minimum benefits required by the federal Affordable Care Act and was intended to reduce state health insurance mandates.  MMA opposed the bill.   

[return to top]

MMA Legislative Committee Call, Tuesday Night at 8:00 pm

The MMA's Legislative Committee has held very successful weekly conference calls so far this session.  They have been well attended and we appreciate the individuals and specialty societies that took the time to participate in the call and share their feedback on pending legislative proposals. 

The next call is tomorrow night, Tuesday, April 3rd at 8:00 p.m.  Legislative Committee members and specialty society legislative liaisons are strongly encouraged to participate.  Any physician, practice manager, or other staff member who is interested in the MMA's legislative advocacy also is welcome to participate.  It is not necessary to RSVP for the calls.

Please use the following conference call number and passcode.  These will remain the same for every weekly call during the session:

Conference call number:  1-877-669-3239

Passcode:  23045263

The purpose of the weekly conference calls is to review and finalize the MMA's position on bills printed that week, to hear the views of specialty societies on the new bills or their concerns about any health policy issues, and to discuss the highlights of legislative action that week.  The calls rarely last longer than an hour and usually we can accomplish our business in much less time.  There have been no new bills introduced since the last call, so we will cover the ongoing budget negotiations and other pending issues at the State House.  For the full list of bills the MMA is currently tracking, click here

If you have any questions about the conference calls, please contact Andrew MacLean, Deputy EVP at amaclean@mainemed.com or 622-3374, ext. 214.

[return to top]

One Hundred Ten Practices Apply for Second Phase of Medical Home Pilot

Interest is very high in the second round of the multi-payer Patient Centered Medical Home Pilot.  One hundred and ten primary care practices met the application deadline last week.  The practices will be evaluated and an announcement will be made by the end of August regarding the twenty practices that will be admitted to the project on January 1, 2012.  There are currently twenty-six practices participating in phase one of the pilot project.

"As Chairman of the Board of Quality Counts, I could not be more proud of the interest in the project.  I find it simply astounding that over one hundred practices are interested in participating in phase two", said Gordon Smith, Executive Vice President of the Maine Medical Association.  "I congratulate Dr. Letourneau and all of the Quality Counts staff for achieving this milestone."

The payers in the pilot include Medicare, MaineCare, Aetna, Harvard-Pilgrim and Anthem.

[return to top]

MMA and the Learning Center at Baker, Newman & Noyes Annual Coding Seminar Friday, April 6

The Maine Medical Association and the Learning Center of Baker, Newman & Noyes present the Annual Coding Seminar as part of MMA's First Friday CME series on April 6, 2012 from 9:00am to noon.  The seminar is available either live at the MMA office in Manchester or via webex.  There is a charge of $65 per person.

Faculty for the seminar includes Laurie Desjardins, CPC, PCS, Jana Purrell, CPC-I, CEMC, and Gordon H. Smith, Esq.

More information and an agenda are available on the MMA website at www.mainemed.com.  You may also register for the program on the website.

  [return to top]

MaineCare Extends 5010 Compliance Deadline

MaineCare is extending the deadline for HIPAA Version 5010 compliance to align with the Centers for Medicare & Medicaid Services (CMS) announcement that it will not initiate enforcement of HIPAA Version 5010 until June 30, 2012.

If your organization submits electronically in batches to MaineCare, you must complete certification testing by June 30, 2012. To certify, you must log in to the MIHMS Health PAS Online Portal.  MaineCare will continue to accept HIPAA Version 4010 transactions through June 30, 2012.

On July 1, 2012, any HIPAA Version 4010 transaction submitted to MaineCare will be rejected.

If you have completed HIPAA Version 5010 certification testing, you are strongly encouraged to submit claims in the 5010 format.

Testing resources are available. Visit the HIPAA Version 5010 webpage for background information, testing instructions, and Frequently Asked Questions about testing HIPAA Version 5010 transactions with MaineCare.

MIHMS Provider inquiries can be directed to 1-866-690-5585.

[return to top]

CMS Response Regarding Medicare Participation & Covered Services

The Centers for Medicare and Medicaid Services (CMS) has responded in writing to the request of the AMA and over 70 state and medical specialty societies regarding the policy for Medicare-covered services furnished by physicians who do not enroll in Medicare.  

 In the letter, CMS confirmed that physicians can enroll in Medicare as a participating (PAR) or non-participating (non-PAR) physician, or they can choose to opt-out of Medicare and furnish services to Medicare beneficiaries under private contracts.  

CMS stated that Medicare requires physicians to enroll in Medicare in order to bill for services furnished to Medicare beneficiaries, whether directly from Medicare or from the beneficiary who is, in turn, reimbursed by Medicare.  

In addition, if a physician furnishes a covered service to a beneficiary, the physician is required to complete a claim form and submit it to Medicare on behalf of the beneficiary, even if the physician is not enrolled in Medicare.  Penalties can apply to physicians who do not follow this requirement.   CMS also explained that CMS Form-1490S (which allows beneficiaries to seek Medicare payment) is rarely used since contractors are encouraged to educate physicians about the requirement to submit claims, but is intended to protect a beneficiary’s right to a payment determination in situations where a physicians refuses to submit a claim for a covered service on behalf of the beneficiary.   

[return to top]

CMS e-Prescribing Penalty Review

CMS has confirmed that the QualityNet Help Desk is now prepared to take calls from physicians on the Medicare e-prescribing penalty.  We understand that physicians have already attempted in the past few weeks to contact the Help Desk to discuss their individual situation which resulted in a 2012 penalty, but in many cases were turned away.  CMS has been working diligently with the Help Desk to ensure that a physician's case is adequately reviewed.  CMS wants physicians to know that the issues they are having are being examined. 

As CMS has indicated late last week, although there is no formal appeals or review process for the e-prescribing penalty, they encourage physicians with questions or concerns about their penalty and / or hardship exemption request to contact CMS' QualityNet Help Desk as soon as possible. CMS is handling all penalty and / or hardship exemption requests and any questions or concerns on a case-by-case basis.  

Physicians should continue to contact the QualityNet Help Desk if they have issues relating to the e-prescribing penalty.  If a physician has previously contacted the QualityNet Help Desk and their case has been resolved to their satisfaction, the physician does not need to contact the QualityNet Help Desk again. 

The QualityNet Help Desk can be reached M-F; 7:00 am – 7:00 pm CMT at 866-288-8912 or via email at qnetsupport@sdps.org.

NOTE:  If a physician continues to experience problems with the Help Desk, CMS is encouraging physicians to email their concerns directly to Medicare at eRx_hardship@cms.hhs.gov

[return to top]

Upcoming Events & Conferences

Cancer in the Family: Primary Care Matters

April 13, 2012 


The Jackson Laboratory 

 600 Main Street

Bar Harbor, ME

This half day free CME event will be held in conjunction with the annual meeting of the Maine Academy of Family Physicians with the goal of enhancing Maine health care providers' understanding of detecting and managing individuals with familial cancer syndromes.

For more information or to register, click here.


The Maine Gastroenterology Society

Gastroenterology 2012 Update

April 14, 2012 

Harraseeket Inn, Freeport, Maine. 

Expand your knowledge of Gastroenterology  in areas including management of ascites, encephalopathy and dysphagia; hepatocellular cancer screening; treatment of IBS.  Open to Primary Care Physicians, Family Practitioners and Allied Health Professionals that want to broaden their knowledge of Gastroenterology

For more information or to register, contact Gail Begin at gbegin@mainemed.com or 207-622-3374 ext. 210.


Immunization Annual Conference: Focus on Maine

Monday, April 23, 2012 

8:00 am - 3:45 pm 

Augusta Civic Center

Sponsored by the Maine Center for Disease Control and Prevention

 Dedicated to a review of emerging and existing issues relating to immunization practice, at the federal, state and local levels.

For more information or to register, click here.



11th Annual Obesity Workshop 

Price Matters: Sugar Sweetened Beverages, Taxes & Obesity - The Evidence 

May 3, 2012

8:00 am - 3:00 pm 

Maple Hill Farm, Hallowell

The annual obesity workshop is an event not-to-miss for all people interested in public health and the health of our children.  Three nationally known speakers will present the latest research and information about sugar sweetened beverages, how they impact obesity rates and how purchase price influences our choices.

For more information or to register, click here


The Maine Society of Eye Physicians and Surgeons Spring Meeting

May 4, 2012 

12:00pm - 4:45pm

Harraseeket Inn, Freeport

The Spring Meeting will include lunch, educational presentations and a business meeting.  The educational talks include Trexler M. Topping, MD presenting on Lessons Learned from Malpractice Claims and Bradford Shingleton, MD presenting on Pseudoexfoliation:  IOP, Cataract Surgery and Postoperative IOL Issues.

For more information or to register, contact Shirley Goggin at sgoggin@mainemed.com or 207-445-2260.


Back to School: Pediatric and Adolescent Hot Topics and School Based Health

May 5-6, 2012

Harborside Hotel, Bar Harbor 

Approved for 10.5 Hours of Category 1 CME 

For more information or to register, go to www.maineaap.org 


Maine Association Medical Staff Services Biennial Education Conference: The Many Spokes of the Wheel

 May 9-11, 2012

 Residence Inn Hotel and Conference Center

Portland, ME

The conference welcomes physicians and other health professionals with an interest in medical staff activities, including credentialing and quality improvement.  Category I CME is offered for physicians.

An agenda and registration materials are available at www.meamss.org


22nd Annual Maine GERIATRICS Conference - Save the Date

June 7-8, 2012 

Harborside Hotel & Marina

Bar Harbor, ME

Registration Open.  CME Available. 

 For more information or to register visit http://www.une.edu/com/cme/


Save the Date: 

Emergency Ultrasound Course

October 25-26, 2012

MaineGeneral Medical Center

Waterville, ME 

Primarily geared to emergency and intensivist physicians and mid-levels.  Expected 14 Category 1 CME Credits.  Course Director: John Joseph, MD, FACEP 

To reserve your spot: 626-1303 or sharon.judkins@mainegeneral.org

[return to top]

Portland Gastroenterology Center Seeking Nurse Practitioner

Are you looking to maximize your professional career? Portland Gastroenterology Center is one of the leading providers of G.I. health care in Maine and Northern New England and we are looking for a dedicated Nurse Practitioner to join our team!

Our Nurse Practitioners are an integral part of our practice; performing patient follow up and consultative clinical evaluation, conducting physical exams, preparing treatment plans, and providing patients with health and disease prevention information.

Candidates should have advanced knowledge and skills in conducting physical examinations and treating patients in an expanded practice model with minimal direction. An advanced knowledge of nursing theory and practice, and additional specialized training acquired through completion of a concentrated study and clinical internship leading to a Master’s Degree. Applicants should have or be eligible to obtain a current license and registration to practice as a certified Advanced Practice Nurse in the State of Maine.

We offer a competitive salary and benefits packet.

If you have always wanted to live in a vibrant city that offers affordable housing, excellent schools, and an energetic arts community, then Portland, Maine is for you!

Resumes should be sent to: TABERA@mmc.org


[return to top]


Beginning today, The Weekly Update will feature one MMA member benefit during the first week of each month.  We do this in an effort to better inform our members and practice staff of the many resources MMA has available to assist in the increasingly complex daily practice of medicine.

This month, we want to remind members and prospective members that MMA's three attorneys are available to provide a legal review of the provisions in any contract relating to the practice, whether from a health plan or an employment contract.  A $250 flat fee is charged regardless of the time involved or the complexity of the contract.  Many residents stepping out into practice as well as members facing employment contracts for the first time have found value in these reviews and consultations.

Through an agreement with the Downeast Association of Physician Assistants, the MMA also offers this service to PA's who are DEAPA members.  The fee for DEAPA members is $150.

MMA members or DEAPA members wishing to have a contract reviewed should contact Gordon Smith, Esq., EVP or Andrew MacLean COO and General Counsel via e-mail to gsmith@mainemed.com or amaclean@mainemed.com respectively.  

[return to top]

Seeking Vascular Surgeon for Prelitigation Screening Panel

The MMA is seeking a vascular surgeon from outside Cumberland County who is willing to volunteer to serve on a prelitigation screening panel.  The work typically takes around a day.  If interested, please contact MMA EVP Gordon Smith at gsmith@mainemed.com or 207-622-3374 x 212. [return to top]

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