Archive for January, 2011

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Annual Wellness Visit Claims

Tuesday, January 25th, 2011

The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 7079 on December 3, 2010, which directed the implementation of Medicare’s annual wellness visit (AWV) under Section 4103 of the Affordable Care Act. Coverage and payment of the AWV were effective January 1, 2011.

Some providers billing for the AWV have included the “routine service” diagnosis code on their claims. Moreover, because Medicare does not pay for routine services, some contractors apply auto-deny edits whenever this “routine service” diagnosis is included on the claim. Consequently, some contractors are denying AWV claims when they should be paid.

CMS has directed contractors to not auto-deny claims for Healthcare Common Procedure Coding System (HCPCS) codes G0438 and G0439 when billed for an AWV in accordance with CR 7079. Based on this direction, National Government Services omitted the editing for diagnosis code V70.0 that is allowable with HCPCS codes G0438 and G0439, and claims that were initially denied are being reprocessed.

Thank you,

National Government Services, Inc.

Posted in MEDICARE UPDATES | No Comments »

COLLECTIVE NEGOTIATION LEGISLATION Re-Introduced

Tuesday, January 25th, 2011


Assembly Majority Leader Ron Canestrari has re-introduced legislation (A.2474) that would permit independently practicing physicians the ability to negotiate collectively patient care terms with health insurance companies, under close state supervision. With nearly 80% of the enrollees in the commercial managed care market in New York State enrolled in just six health insurance behemoths, and most regions of the state dominated by just one or two health plans, most physicians face “take it or leave it” contracts that do not afford them any realistic ability to negotiate important plan participation terms. Enactment of this legislation is one of MSSNY’s highest priorities for the 2011 Legislative Session.

Co-sponsors of this legislation are Assemblymembers: Gottfried, Cahill, Colton, Magnarelli, Galef, Paulin, Schimel, Lifton, Cusick, O’Donnell, Abbate, Aubry, Bing, Brennan, Cook, Cymbrowitz, Destito, Dinowitz, Englebright, Glick, Heastie, Hikind, Hooper, Jacobs, Latimer, V. Lopez, Lupardo, Magee, Markey, McEneny, Meng, Millman, Morelle, Ortiz, Pheffer, Pretlow, Raia, Scarborough, Spano, Sweeney, Towns, Weinstein, and Wright. Physicians are urged to contact sponsors from their area to thank them for their sponsorship. Please urge your local legislators to join on as co-sponsors of this legislation if not listed already!

Posted in NEWS FROM THE NYS LEGISLATURE | No Comments »

Massaupequa Office Building For Sale Or Lease

Tuesday, January 18th, 2011

511 Ocean Avenue
Price Reduced On Office Building For Sale Or Lease
Located At The Massapequa Train Station
Sale Of Building Includes Large Private Parking Lot
For Pictures And More Information:

Contact David Harris 516-319-5352 or e-mail David.Harris@elliman.com

Posted in CLASSIFIED ADS | No Comments »

Supreme Court: Medical Residents NOT Exempt from FICA Taxes

Tuesday, January 18th, 2011

On January 11, the US Supreme Court ruled unanimously that medical residents are not exempt from paying employment taxes under the Federal Insurance Contributions Act (FICA), and that medical residents should be considered employees when it comes to collecting Social Security taxes. This ruling in Mayo Foundation for Medical Education and Research v. United States will have a wide-ranging impact on health care and teaching hospitals and involves an estimated $700 million in employment taxes annually.

“The department certainly did not act irrationally in concluding that these doctors — ‘who work long hours, serve as high skilled professionals, and typically share some or all of the terms of employment of career employees’ — are the kind of workers that Congress intended to both contribute and benefit from the Social Security system,” said Chief Justice John Roberts, who wrote the opinion for the court.

Under the Social Security Act, medical residents were exempt from FICA taxes under an exception carved out for those performing services “in the employ of…a school, college, or university…if such service is performed by a student who is enrolled and regularly attending classes at such school, college or university.”  However, Mayo officials argued that residents fall under a Social Security tax exemption for student employees whose work is part of their education. The Treasury Department took away that exemption in 2004 for medical students who work more than 40 hours per week. Mayo Clinic officials wanted the court to overturn a federal appeals court ruling and restore the student exemption for medical residents. It also wanted a refund of the money it had withheld and paid to the IRS on its residents’ stipends during the second quarter of 2005.

In arguments before the Supreme Court, Mayo’s lawyer argued that the IRS’ decision that anyone who works over 40 hours a week at a hospital can no longer be classified as a student was arbitrary and capricious.

The Supreme Court decision is available at http://www.supremecourt.gov/opinions/10pdf/09-837.pdf

Posted in NATIONAL HEALTHCARE NEWS | No Comments »

New Workers’ Compensation Brochure — “Get the Facts on Medical Treatment Guidelines”

Tuesday, January 18th, 2011

Many medical providers requested that a brochure be created to educate injured workers on the new Medical Treatment Guidelines. “Get the Facts” on Medical Treatment Guidelines, is a brochure issued by the NYS Workers’ Compensation Board. This brochure is available on the Board’s website at:

http://www.wcb.state.ny.us/content/main/Workers/MTGFacts.pdf

The link is case sensitive.

Posted in WORKERS' COMPENSATION UPDATES | No Comments »

Legal Challenges to the Affordable Care Act

Friday, January 14th, 2011

Jan. 13, 2011

Given the new direction for the nation’s health system, the AMA has developed Health System Reform Insight to help you understand the health system reform legislation and what it means to you and your patients.

A key component of the Affordable Care Act (ACA) is a provision—effective in 2014—that requires most individuals to purchase health insurance or pay a penalty. In addition, the ACA significantly expands health insurance coverage to the uninsured through the Medicaid program. Since passage of the ACA, numerous lawsuits have been filed, several of which are summarized below, challenging the constitutional authority of Congress to enact an individual mandate and expand the Medicaid program.

Individual mandate

Section 1501 of Title I of the ACA requires that most individuals maintain minimum essential health insurance coverage for themselves and their dependents. Those who fail to do so will be required to pay a penalty, administered through the tax code for each month of noncompliance. Qualified individuals will be provided subsidies to help pay for their premiums and cost-sharing. Others will be exempt from the individual mandate, including those with qualifying religious exemptions, those in a health care sharing ministry, individuals not lawfully present in the United States and incarcerated individuals. No penalty will be imposed on those without health insurance coverage for less than 90 days, members of Indian tribes, individuals whose household income does not exceed 100 percent of the federal poverty level (FPL), or any individual who is determined by the secretary of Health and Human Services to have suffered a hardship with respect to being able to obtain health insurance coverage under a qualified health plan.

The individual mandate is generally consistent with AMA policy, which states that individuals and families earning greater than 500 percent of FPL should be required to obtain health insurance coverage for at least catastrophic health care and evidence-based preventive health care. For those earning less than 500 percent of FPL, the individual responsibility requirement is supported only upon implementation of a system of refundable tax credits or other subsidies to help obtain health insurance coverage. AMA policy also supports using the tax structure to achieve compliance.

Medicaid expansion

The Medicaid provisions in the ACA significantly expand Medicaid eligibility. Beginning in 2014 or earlier if the state chooses, nonelderly, nonpregnant individuals with income below 133 percent of FPL will be newly eligible for Medicaid. The ACA also adds new mandatory benefits that states must cover. From 2014 to 2016, the federal government will cover 100 percent of the Medicaid costs of these newly eligible individuals, with the percentage dropping to 90 percent and the states covering the difference by 2020. AMA policy supports maintaining Medicaid as a safety net program and covering all individuals with incomes below the poverty level.

Constitutional challenges

Since its enactment, several lawsuits have been filed challenging the constitutionality of various provisions of the ACA. Although challenges to the law have deployed a wide range of constitutional arguments, the main questions are whether the individual mandate is a permissible exercise of congressional power under the commerce clause in Article 1 of the Constitution, whether the individual mandate (if ruled to be unconstitutional) can be “severed” from the rest of the ACA (leaving intact other provisions in the ACA), and whether the expansion of the Medicaid program under the ACA is “coercive” to states.

Summary of cases

Commonwealth of Virginia v. Sebelius (U.S. District Court, Eastern District of Virginia)
On Dec. 13, 2010, in the first ruling against the constitutionality of the individual health insurance mandate, Judge Henry Hudson held that the ACA’s mandate that all individuals must purchase health insurance or pay a penalty is unconstitutional. This ruling, however, is limited to Section 1501 of the ACA (the minimum essential coverage provision). And because the ACA does not include a severability provision (i.e., maintaining the rest of the statute when one provision is determined to be unconstitutional), he exercised his judicial discretion to sever Section 1501 from other provisions of the law. Judge Hudson also declined to issue an injunction blocking the entire law, noting that the mandate does not take effect until 2014, and that his ruling would most likely not be the final word on this issue. Further, Judge Hudson rejected the government’s claims that the ACA was valid under the Constitution’s “necessary and proper” clause, and that the penalty for failing t obtain health insurance is a tax that could be upheld under the “general welfare” clause. This case most likely will be appealed to the U.S. Court of Appeals for the Fourth Circuit.

State of Florida v. U.S. Department of Health and Human Services (U.S. District Court, Northern District of Florida)
This lawsuit was brought by 13 states (there are now 20 participating states and the National Federation of Independent Business) challenging the constitutionality of the individual health insurance mandate and the expansion of Medicaid. On Oct. 14, 2010, Judge Roger Vinson dismissed four of the six claims in the lawsuit. The two remaining claims involve the constitutionality of the individual mandate as an exercise of congressional authority to regulate interstate commerce and make laws “necessary and proper” for carrying out its powers, as well as the claim that expansion of the Medicaid program is coercive because it “coerces and commandeers” states to devote their limited financial resources to achieve federal aims, thereby violating the 10th Amendment to the Constitution. Oral arguments on the merits of the case, as well as motions for summary judgment from both sides, were heard on Dec. 16, 2010.

Thomas More Law Center v. Obama (U.S. District Court, Eastern District of Michigan)
On Oct. 7, 2010, Federal District Court Judge George Steeh dismissed this case, and found the individual mandate constitutional under the commerce clause. This case has been appealed to the U.S. Court of Appeals for the Sixth Circuit.

Liberty University, Inc. v. Geithner (U.S. District Court, Western District of Virginia)
On Nov. 30, 2010, Federal District Court Judge Norman Moon ruled that the requirement that most Americans obtain health insurance coverage falls within Congress’ authority to regulate interstate commerce. This case has been appealed to the U.S. Court of Appeals for the Fourth Circuit.

What happens next?

After the Courts of Appeals issue their rulings, it is widely expected that the constitutional challenges to the ACA ultimately will be determined by the U.S. Supreme Court, most likely this year or in 2012.

For more information

Visit the ACA litigation blog website for news, legal analysis and official documents related to ACA legal challenges.

Posted in NATIONAL HEALTHCARE NEWS | No Comments »

2011 Electronic Prescribing (eRx) Incentive Program Update

Monday, January 10th, 2011


In November, the CMS announced that, beginning in 2012, eligible professionals who are not successful electronic prescribers may be subject to a payment adjustment on their Medicare Part B Physician Fee Schedule (PFS) covered professional services. Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes CMS to apply this payment adjustment whether or not the eligible professional is planning to participate in the eRx Incentive Program.

From 2012 through 2014, the payment adjustment will increase each calendar year.  In 2012, the payment adjustment for not being a successful electronic prescriber will result in an eligible professional or group practice receiving 99% of their Medicare Part B PFS amount that would otherwise apply to such services.  In 2013, an eligible professional or group practice will receive 98.5% of their Medicare Part B PFS covered professional services for not being a successful electronic prescriber in 2011 or as defined in a future regulation. In 2014, the payment adjustment for not being a successful electronic prescriber is 2%, resulting in an eligible professional or group practice receiving 98% of their Medicare Part B PFS covered professional services.

The payment adjustment does not apply if <10% of an eligible professional’s (or group practice’s) allowed charges for the January 1, 2011 through June 30, 2011 reporting period are comprised of codes in the denominator of the 2011 eRx measure.

Please note that earning an eRx incentive for 2011 will NOT necessarily exempt an eligible professional or group practice from the payment adjustment in 2011.

How to Avoid the 2012 eRx Payment Adjustment

  • Eligible professionals – An eligible professional can avoid the 2012 eRx Payment if (s)he:
  1. Is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of June 30, 2011 based on primary taxonomy code in NPPES;
  2. Does not have prescribing privileges. Note: (S)he must report (G8644) at least one time on an eligible claim prior to June 30, 2011;
  3. Does not have at least 100 cases containing an encounter code in the measure denominator;
  4. Becomes a successful e-prescriber; and
  5. Reports the eRx measure for at least 10 unique eRx events for patients in the denominator of the measure.


·         Group Practices – For group practices that are participating in eRx GPRO I or GPRO II during 2011, the group practice MUST become a successful e-prescriber.

Depending on the group’s size, the group practice must report the eRx measure for 75-2,500 unique eRx events for patients in the denominator of the measure.


For additional information, please visit the “Getting Started” webpage at http://www.cms.gov/erxincentive on the CMS website for more information; or download the Medicare’s Practical Guide to the Electronic Prescribing (eRx) Incentive Program under Educational Resources.

Posted in MEDICARE UPDATES, NATIONAL HEALTHCARE NEWS | No Comments »

Medicare Sets Physician Payment Rates In 2011

Monday, January 10th, 2011

Following passage of the Medicare and Medicaid Extenders Act of 2010—which President Obama signed on December 15—the Centers for Medicare & Medicaid Services (CMS) adjusted its calculations of the 2011 Medicare payment rates that had been published in the final rule. CMS issued a final 2011 conversion factor of $33.9764 and provided new files to the Medicare carriers. The carriers have been testing the new files and are in the process of posting them to their websites. All 2011 claims are expected to be paid on time and at the correct rates with no adjustments or claims holds necessary.

Click here to view the new payment schedule file. Download the zip file RVU11AR to view the final 2011 relative values, which are in the file PPRRVU11.xlsx. To learn more, visit here and view instructions CMS sent to its carriers.

Posted in MEDICARE UPDATES, NATIONAL HEALTHCARE NEWS | No Comments »

Potential Hepatitis A Exposure at a Local Church

Thursday, January 6th, 2011

SUMMARY
Nassau County Department of Health (NCDOH) has identified a case of acute hepatitis A in an individual associated with Our Lady of Lourdes Church, located at 855 Carmans Road in Massapequa Park. In consultation with the New York State Department of Health and the Centers for Disease Control and Prevention, Nassau County Department of Health recommends that individuals that received Holy Communion at any of the masses receive post exposure prophylaxis (PEP) against hepatitis A.
• Christmas Day, December 25, 2010 at the 10:30am, 12 Noon and 1:30 pm
• Sunday, December 26, 2010 at 7:30 am, 9:00 am, 10:30 am, 12 pm and 1:30 pm
Persons who have been vaccinated for hepatitis A or have had the illness in the past are protected from hepatitis A infection, and there is no need for further action, despite the potential exposure. NCDOH will be holding a PEP clinic on Friday, January 7, from 7:00 am to 12:00 pm at
Our Lady of Lourdes Church School Auditorium 855 Carmans Road in Massapequa Park. PEP will also be available that day by appointment only at NCDOH, 106 Charles Lindbergh Boulevard in Uniondale. Individuals interested in making an appointment can
call 516.227.9496.

Providers are encouraged to consider and test for hepatitis A in patients with jaundice, abdominal pain, fever, nausea, and diarrhea with a history of exposure at these masses. Providers should report suspected and confirmed cases of hepatitis A promptly to NCDOH at 516.227.9496. Suspected cases of hepatitis A in a food worker should bereported immediately.
BACKGROUND
Hepatitis A is caused by the hepatitis A virus. Hepatitis A virus may be spread by consuming food or drink that has been handled by an infected person. It may also be spread from person to person by putting something in the mouth that has been contaminated with the stool of a person with hepatitis A. Casual contact, as in sitting in church during mass, office or school setting, does not spread the virus.
The symptoms of hepatitis A may range from mild to severe and include an abrupt onset of fever, fatigue, poor appetite, nausea, stomach pain, dark-colored urine and jaundice (a yellowing of the skin and whites of the eyes). The disease is rarely fatal and most people recover in a few weeks without any complications. The symptoms commonly appear within 28 days of exposure, with a range of 15-50 days. There are no special medicines or antibiotics that can be used to treat a person once symptoms appear. Generally bed rest is all that is needed. Thorough hand washing after bathroom use and before, during and after food preparation is the most important means to prevent the spread of this and other intestinal illnesses. Sharing of food and utensils should be discouraged especially whenever anyone is ill.
RECOMMENDATIONS FOR PROPHYLAXIS OF EXPOSED PERSONS
The Centers for Disease Control and Prevention (CDC) recommends that persons who are not protected and are within 14 days of exposure receive a dose of single antigen hepatitis A vaccine or immune globulin (IG).
• For healthy persons age ≥ 12 months to 40 years, hepatitis A vaccine at the age
appropriate dose is preferred to IG because of vaccine’s advantages, including long term
protection and ease of administration.
• For persons > 40 years of age, IG plus vaccine is preferred because of the absence of
information regarding vaccine performance and the more severe manifestations of
hepatitis A in this age group.
• IG should be used for immunocompromised persons, persons who have been diagnosed
with chronic liver disease, and persons for whom vaccine is contraindicated.
A clinic has been scheduled to provide post-exposure prophylaxis (PEP) for exposed persons on Friday, January 7, from 7:00 am to 12:00 pm at Our Lady of Lourdes Church School Auditorium 855 Carmans Road in Massapequa Park. PEP will also be available that day by appointment only at NCDOH, 106 Charles Lindbergh Boulevard in Uniondale. Individuals interested in making an appointment can call 516.227.9496. PEP had previously been offered at NCDOH clinics on January 4 and January 5. Persons who have been vaccinated for hepatitis A or have had the illness in the past are protected from hepatitis A infection, and there is no need for further action. Those persons eligible for vaccination or immune globulin (IG) at the NCDOH clinic must meet EACH of the following requirements:
1. Received Holy Communion at Our Lady of Lourdes Church on at any of the following
masses:
• Christmas Day, December 25, 2010 at the 10:30am, 12 Noon and 1:30 pm
• Sunday, December 26, 2010 at 7:30 am, 9:00 am, 10:30 am, 12 pm and 1:30 pm
AND
2. Have no prior history of immunization against hepatitis A or diagnosis of hepatitis A
infection.
DIAGNOSIS
NCDOH is asking providers to consider hepatitis A infection when evaluating any patient with jaundice with or without abdominal pain, fever, nausea, and/or diarrhea. Hepatitis A infection should also be considered for persons without jaundice who present with abdominal pain, fever, nausea, and/or diarrhea and have a history of receiving Holy Communion at Our Lady of Lourdes Church at the above referenced dates and times. For symptomatic persons, physicians should order serologic tests for hepatitis A virus (HAV) (total and IgM anti-HAVantibody, available commercially). Due to the possibility of false positive results, serologic tests for HAV should not be used to identify infection
in those exposed who received Holy Communion but have no symptoms. However, for exposed patients under the age of 6 with milder symptoms, especially those in daycare or school settings, testing should be considered. Positive total anti-HAV and negative IgM anti-HAV indicates past infection or vaccination and immunity.
REPORTING
Providers should report suspected and confirmed cases of hepatitis A promptly to NCDOH at 516.227.9496. Suspected cases of hepatitis A in a food worker should be reported immediately by phone.
ADDITIONAL INFORMATION
For additional information on the potential hepatitis A exposure at Our Lady of Lourdes Church, please call the Nassau County Department of Health at 516.227.9496 between the hours of 9:00 am and 4:45 pm. Additional information on hepatitis A is available on the Nassau County Department of Health web site at http://www.nassaucountyny.gov/agencies/Health/index.html

Posted in HEALTH DEPARTMENT UPDATES | No Comments »

Rules on Failure to Treat WC Patients

Thursday, January 6th, 2011

NEW YORK CODES, RULES AND REGULATIONS, NYCRR 325-1.21 provides in part that a physician, “shall accept and treat such injured employees in a manner corresponding to that accorded other patients in his or her practice, without discriminating against such injured employees because they are or may be covered by the provisions of the Workers’ Compensation Law”.  The full text of NYCRR 325.21 is included below.

Section 325-1.21 Failure to treat.

A physician, podiatrist, chiropractor, psychologist, operator of a medical bureau or laboratory authorized by the chair to render treatment and care to injured employees under the Workers’ Compensation Law:

(a) shall accept and treat such injured employees in a manner corresponding to that accorded other patients in his or her practice, withoutdiscriminating against such injured employees because they are or may be covered by the provisions of the Workers’ Compensation Law; and

(b) shall not refuse to provide treatment and care to such injured employees on the basis of a fee request greater than that set forth in the applicable prescribed fee schedule, but shall submit to arbitration such fee dispute in accordance with the provisions of the Workers’ Compensation Law, nor shall such treatment and care be denied to such injured employees because the source or manner of payment for such treatment and care is pursuant to the provisions of the Workers’ Compensation Law.

Nothing contained in this section shall prevent a voluntary payment by the employer or carrier of an amount higher than the fees and charges found in the fee schedule where agreed to by the employer or carrier. An authorized physician, podiatrist, chiropractor, psychologist, operator of a medical bureau or laboratory whose actions violate or are inconsistent with the provisions of this section shall be charged with misconduct, and his or her authorization to treat workers’ compensation cases shall be subject to suspension or revocation by the chair in accordance with the procedures set forth in the Workers’ Compensation Law.

Q. What is the consequence of Failure to Treat?

A.   A provider can be removed from the list of authorized providers.

Q.  If a physician can’t take on any new WC claimants, would the WCB consider this reportable misconduct?

A.  If a provider is removed from the list of authorized providers, it is reportable to DOH.

Q.  What if the practice cannot financially sustain any more WC claimants?

A.  As the regulation states, “shall accept and treat such injured employees in a manner corresponding to that accorded other patients in his or her practice, without discriminating against such injured employees because they are or may be covered by the provisions of the Workers’ Compensation Law.”

Q.  As an example under managed care, doctors may feel they need to close their panel since it is not economically sustainable to take on new plan patients.

A.  The only acceptable reason not to take on new WC patients is if the practice is not taking on ANY new patients.

Q.  What is the alternative if a physician feels h/she cannot sustain the financial viability of the practice without limiting the number of WC claimants?

A.  The physician may have to turn in their authorization to treat WC patients and cease treating all WC patients.

Q.  Are you saying that the physician has no discretion to limit the number of WC claimants?

A.  Their discretion is limited only to the extent that they may refuse a new WC patient if the practice is not accepting ANY new patients.

Posted in WORKERS' COMPENSATION UPDATES | No Comments »

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