The New York State Insurance Department this week implemented a regulation prohibiting insurers and HMOs from returning claims for payment submitted by physicians as incomplete if the claim form contains certain data elements. The regulation applies to non-electronically submitted claims, including those sent by mail or fax (electronic claims were excluded because they will be governed by the HIPAA Standard Transaction sets as of October 16, 2003). Insurers and HMOs will continue to be permitted to request other information separate and distinct from the claim form in order to process a claim, such as additional medical documentation to justify higher levels of service.

The goal of this regulation is to reduce attempts by health plans to return unpaid claims to physicians asking for further information. The regulation was negotiated by the “Prompt Pay Roundtable” convened by the State Insurance Department. The participants included MSSNY, the Healthcare Association of New York State and the New York Health Plan Association. The adoption of a uniform definition of a “clean claim” is the first significant development of what MSSNY hopes to be many other resolutions to problems that physicians encounter when they submit claims for reimbursement for patient care to insurers.

Other issues MSSNY will raise to be addressed at future roundtable meetings include insurer refund demands and coordination of benefit problems. The full text of the “clean claim” regulation, including the fields on the CMS-1500 that need to be accurately completed, can be accessed from the Insurance Department web site at:

 http://www.ins.state.ny.us/acrobat/re178txt.pdf.

MSSNY, together with several other health care provider organizations and patient advocacy organizations, continue to advocate for the restoration of Medicaid funding for the coinsurance costs associated with the “dual eligible” population. In conjunction with these efforts, MSSNY continues to request that physicians take the following steps to apprise lawmakers of their concern regarding the impact of this cut:

• Call the “Restore Crossover” hotline, 1-866-867-8829. Each call will generate a letter to Governor Pataki, Speaker Silver and Senate Majority Leader Bruno expressing concern with the cut and urging immediate restoration;
• Encourage your patients to call this hotline as well. Each of their calls will generate a patient-focused letter on this issue to the aforementioned three leaders; and
• Contact MSSNY’s Grassroots Action Center at: http://www.mssny.org to send a letter to your Assembly member and Senator to urge support for restoration of this cut.
• Your action is essential to helping secure the restoration of these funds.

The Nassau County Department of Health reminds residents that the best way to protect yourself and your family from the flu and its complications is to get immunized every year. Immunization could prevent you from catching the flu or it could lessen the severity of the disease.
Remember, an individual cannot get the flu from the flu shot. The following are persons at highest risk who should be immunized.

They include:

• People aged 65 and older
• Adults and children with chronic cardiovascular and pulmonary disorders, including asthma
• Adults and children with chronic metabolic diseases, including diabetes, renal dysfunction and weakened immune systems
• Children and teenagers receiving long-term aspirin therapy
• Residents and staff of nursing homes and chronic care facilities
• Health care workers with direct patient contact
• Pregnant women with underlying medical conditions
• Healthy pregnant women who will be more than three months pregnant during flu season
• Children ages 6 months to 9 years who have never received a flu vaccine before

In addition, certain individuals are at increased risk for serious influenza-related complications and also should receive flu vaccine:

• People living in a home with individuals at highest risk for complications of influenza
• All adults aged 50 - 64 years
• All children between 6 months and 23 months
• People living in a home with, and care-givers of, children under 2 years of age
• Students and other people in colleges and other institutional settings
• Employees of health care facilities who do not have direct patient contact
• Other people who perform essential community services

All other adults and children age two years and older, who want to reduce their likelihood of becoming ill with flu should contact their health care providers to obtain vaccine.

The New York State Department of Health has diagnosed three additional Nassau County residents with West Nile virus. This brings the total to eight human cases in Nassau County.

One individual is an 85-year-old man who resides in Mineola. Symptoms included fever, headache and muscle weakness. He became ill on August 27th, was hospitalized on September 3rd, discharged on September 11th and is recovering at home.

The second individual is a 61-year-old female from Hewlett. Her symptoms included fever and headache. She became ill on September 2nd, hospitalized on September4th, discharged on September 11th and is recovering at home.

The third individual is a 69-year-old male who resides in Floral Park. Symptoms included fever, headache and muscle pain. He became ill on September 2nd, was hospitalized on September 7th , discharged on September 13th and is recovering at home.

The Nassau County Departments of Health and Public Works have intensified mosquito surveillance activities in the Mineola, Hewlett and Floral Park areas. They are inspecting for breeding sites and, when necessary, will apply larvicide.

Please continue to report dead birds to the New York State Hotline toll free number at 1-866-537-2473 on Monday through Friday from 8:00 a.m. to 4:30 p.m., or to the Department of Health Monday through Friday, between 7:45 a.m. and 3:30 p.m. at (516) 571-8707. Most of the reported birds will not be collected. To call about a mosquito problem, call 571-8707 weekdays from 7:45a.m. to 3:30 p.m. Residents can hear the latest information about West Nile virus by dialing 571-2500. The information is available in English and Spanish 24 hours a day. In addition, West Nile information may be found on the County website at:

 www.co.nassau.ny.us/health.

The Nassau Academy of Medicine's Education Committee is in need of members willing to meet about once a month to help plan and implement CME and other educational programs for the membership.

If you can help, please call the Academy offices at 516-832-2300 ext 13.

Caring for the Chronically Ill in the 21st Century

FRIDAY OCTOBER 24, 2003
8:30 AM TO 3:00 PM

Co-sponsored by People on the Block and Hofstra University's Department of Counseling, Research, Special Education and Rehabilitation in the School of Education and Allied Human Services.

The conference will bring together experts from the field of health care, including but not limited to gerontology and professionals from facilities such as assisted living centers, nursing homes, hospitals, day care centers, senior centers and caregiver organizations.

Professionals from assisted living centers, nursing homes, hospitals, day care centers, and senior centers will meet with government representatives and consumers.

Those wishing to attend the seminar or who wish more information can go to www.peopleontheblock.com or call 631-757-3574.

The second annual New York State Department of Health Hepatitis C Virus Conference, Progress Towards the Effective Management of Hepatitis C Virus (HCV), will be held at the New York Academy of Medicine on November 20, 2003.

Some of the conference speakers include: David Thomas, MD, John Hopkins School of Medicine, Baltimore, MD; Brian Edlin, MD, Center for the Study of Hepatitis C, Weill Medical College of Cornell University; and Stephen Price, MD, Threat Assessment and Risk Management Center.

For information, contact Colleen Flanigan, Hepatitis C coordinator, at 518-473-4439, or e-mail hcvconf@health.state.ny.us to request a conference registration form.

The October 16, 2003 HIPAA Electronic Transactions and Code Sets deadline is rapidly approaching. A medical practice that is covered by the HIPAA Electronic Transaction and Code Sets standard should already have started testing to determine the medical practice’s state of readiness to comply with the standard*. According to some industry experts, if a medical practice does not begin testing by early August – the medical practice will not have enough time to meet the deadline.

Each medical practice covered under the HIPAA Electronic Transactions standard should contact its vendors regarding any updated software needed to comply with the standard, and should be testing its software with payers, including Medicare, Medicaid and commercial payers. If a medical practice uses a clearinghouse, a billing service or a third party administrator to handle billing, the medical practice should obtain the assurance from the entity that it is able to comply with the standard by the October 16, 2003 deadline.

Under the HIPAA Electronic Transactions and Code Set standard medical practices covered by the regulations had until October 16, 2002 to comply with the standard. However, the “Administrative Simplification Compliance Act” signed by President Bush on December 27, 2001 gave medical offices and other covered entities a one year extension - or until October 16, 2003 – if the medical practice or other covered entity submitted a “Compliance Plan” to the U.S. Department of Human Services before October 16, 2002. If no compliance plan was filed, the medical practice or other covered entity is subject to penalties under HIPAA if it engages in non-compliant health care transactions after October 16, 2002.

The Centers for Medicare and Medicaid Services (CMS) is responsible for enforcing the Electronic Transactions standard. On July 24, 2003 CMS issued guidance “Steps Toward HIPAA Compliance” on its website www.cms.hhs.gov/hipaa/hipaa2/guidance-final.pdf. According to CMS, it will use a complaint driven approach for enforcement of HIPAA’s electronic transactions and code set provisions.

When CMS receives a complaint, it will notify the covered entity that it has received a complaint and will ask the covered entity to 1) demonstrate compliance, 2) document its good faith efforts to comply with the standard, and/or 3) submit a corrective action plan.

The guidance provides that CMS will consider an entity’s good faith efforts to comply when assessing individual complaints. CMS states that it may decide not to impose a civil money penalty where the entity demonstrates it is making good faith efforts to comply and the failure to comply is not the result of “willful neglect”. The guidance also states that CMS recognizes that transactions often require the participation of two covered entities (e.g. electronic transactions between medical practice and health plan) and that noncompliance by one covered entity may place the second covered entity in a difficult position. CMS, therefore, states that it intends to look at both covered entities’ good faith efforts to come into compliance in determining, on a case by case basis, whether to impose penalties.

According to CMS, indications of good faith include increased external testing with trading partners prior to October 16, 2003.

Medical industry leaders last week voted against an HHS-commissioned draft proposal to develop a national electronic health records system, the Wall Street Journal reports. The draft broadly addressed the functions of an electronic health records system, including providing instant access to patient information, computerizing medication ordering, checking for drug interactions and conducting public health surveillance. However, officials from groups including hospitals, outpatient clinics, medical associations, managed care organizations, public health agencies and information technology vendors said the proposal was “too complex,” adding that some parts were “too ambiguous” while others were “too specific,” according to the Journal. They also said the draft did not “leave enough room for flexibility.”

HHS Secretary Tommy Thompson in July asked the not-for-profit standards development group Health Level 7 and the Institute of Medicine to develop the proposal. HHS officials said the vote “isn’t a big setback,” adding that it will help them develop a system that is practical. HHS expects to begin some electronic health record demonstration projects next year.

The FDA has approved for the treatment of complicated skin infections the first drug in a new class of antibiotics, the Wall Street Journal (9/13) reports.

The drug, whose chemical name is daptomycin, will be given by injection to treat serious infections caused by members of the staphylococcus family of bacteria. The drug will be marketed under the brand name Cubicin. The drug is part of a continuing effort by the health care industry and the government to develop medicines that are more effective against antibiotic-resistant bacteria. The approval was based on a clinical study of 1,400 patients that showed Cubicin was safe and effective and performed equally well compared with standard drugs, such as vancomycin, oxacillin and nafcillin, used in the treatment of complicated skin and skin structure infections.

Effective September 8, 2003, all insurers, attorneys, licensed representatives and health care providers involved with claims being processed in New York City, Long Island, Westchester, Rockland, Putnam or Orange Counties must direct all claims-related mail correspondence to the following centralized address. Failure to do so could result in unnecessary delays in processing of claims

New York State
Workers’ Compensation Board
PO Box 5205
Binghamton, NY 13902

According to the Deputy Commissioner of Office of Medicaid Management, the New York State Medicaid Management Information System (MMIS) will not be able to accept and process certain HIPAA-compliant transactions by September 27, 2003. Specifically affected are the professional claim (837P), the institutional claim (837I), the dental claim (837D) and the claims inquiry (276) transactions. These transactions should continue to be submitted using the current proprietary format, and will be processed for payment as usual.

The delay has been caused by a number of unanticipated technical systems issues that must be resolved before HIPAA-compliant claim transactions from providers or their billing vendors can be accepted. MMIS will be sharing additional information with physicians as they proceed with implementation efforts. Physicians will be notified at least 14 days in advance of the date when the MMIS Legacy System will be able to accept HIPAA- compliant transactions.

MMIS will be able to accept and process HIPAA-compliant eligibility verification inquiry and response (270, 271), service authorization (278), and NCPDP (retail pharmacy) transactions through the eMedNY system by October 16, 2003.

If you or your billing vendor are not able to submit claim transactions in the current proprietary format after October 16, 2003, please contact Patrick McGuinness at 518-257-4564 or at pjm02@health.state.ny.us to inform him of your situation as soon as possible.

All other questions related to HIPAA implementation should be directed to the CSC HIPAA Support Helpline at 1-866-840-3445.

Due to the flaws in the physician payment update formula, the physician payment crisis continues. In March, Medicare officials projected a cut of 4.2% in 2004 payment rates for physicians and other health professionals. Even steeper cuts are possible and an August 15 proposed rule noted that the estimated update is “highly likely” to change before it is finalized later this year. This cut would be the fifth cut since 1991, and would be on top of an actual reduction of 5.4% in 2002. Without any action by Congress, additional cuts are also estimated for 2005, 2006, and 2007. From 1991-2003, payment rates for physicians and health professionals have already fallen 14% behind practice cost inflation, as measured by Medicare’s own conservative estimates.

In New York alone, $238 million in health care dollars dedicated to treating senior citizens would be lost in 2004, and this would be on top of a $207 million loss already suffered by New York’s seniors as a result of a 5.4% across-the-board payment cut in 2002. The House-passed Medicare bill (H.R.1) would provide relief to the continuing physician payment crisis by establishing positive updates for 2004 and 2005 of not less than 1.5% in each of these years. These provisions would help avert a Medicare meltdown and allow physicians to continue to treat the health care needs of the elderly population. This proposed physician payment increase was included in H.R.1 at the urging of the AMA and MSSNY.

Now, the House and Senate are negotiating over what to include in their final version of Medicare legislation. It is imperative that all physicians contact their own Representative and Senators Charles Schumer and Hillary Clinton to strongly urge that the Medicare physician payment legislation passed by the House in H.R.1 be included in the final conference report on Medicare.

Physicians can easily access their Congressional representatives by phone by using the AMA’s Grassroots Hotline at 800 833-6354 or by sending a letter through MSSNY’s Grassroots Action Center at:

 http://capwiz.com/mssny/issues/alert/?alertid=2212506&type=CO.

On September 11, the New York State Supreme Court, Appellate Division, First Department, in Anonymous v. State Board for Professional Medical Conduct ruled 5-0 that the New York State Board for Professional Medical Conduct (BPMC) may not publish unfounded allegations against a physician.

The New York State Department of Health maintains on its website the Statement of Charges and the Determination and Order involving any physician found guilty of professional misconduct.

The practice challenged by the petitioner physician in Anonymous, is that the Statement of Charges and the Determination and Order are published in their entirety, and include both the factual allegations and specifications of charges that were not sustained against the physician. The physician argued that the publication of allegations that were not sustained by the hearing committee could damage his reputation.

In agreeing with the physician, the Appellate Division directed the BPMC to withdraw from public access those portions of the Statement of Charges and Determination and Order which relate in any way to the allegations which were not sustained against the physician.

(New York Law Journal, September 17)