From the President
From the Statehouse
From the Third Party Payer Consultant
From the Legal Counsel
Asset
Protection
New discounts available to NJSPS members
NJ Life
Health & Beauty Magazine
Register Now
2010 Annual
Meeting
April 17, 2010
The Westin Princeton
At
Forrestal Village
201 Village Boulevard
Princeton, NJ 08540
Surgeon and Administrator programs!
Lectures given by Dr. J. Peter Rubin,
Dr. Dennis Hammond, Dr. Lewis G. Sandy
and many more!
Register at
www.NJSPSmeeting.com
now!
From the President...Gregory L.
Borah, MD, FACS
IMPORTANT MEDICARE
and NJ OUT-OF-NETWORK ADVOCACY
A
Medicare meltdown now seems certain, as the U.S. Senate failed
to repeal the Medicare physician payment formula that will cause
a drastic 21 percent payment cut to physicians who care for
Medicare patients. On March 1, the cut went into effect, forcing
many physicians to limit the number of Medicare patients they
see in order to keep their practice doors open.
A
new 2010 survey of neurosurgeons found that about 60 percent of
doctors are already reducing the number of Medicare patients in
their practices, and cuts will force an additional nearly 40
percent more to decrease the number of new Medicare patients
they see. More than 18 percent of neurosurgeons no longer take
new Medicare patients. Doubtlessly, specialists (including
Plastic Surgeons) will be forced to follow their lead.
In
the 'good old days' we could cost shift and take a loss on
Medicare patients as a public service and still make up for the
losses keeping our practices afloat with insured patients. This
strategy, born of our altruistic inclinations, just set the bar
of reimbursements low and subsequently the health care insurers
took advantage of us and tied their rates to Medicare. These
for-profit insurers were not bound by a sense of obligation to
hold down profits made from seniors, because they were
'businessmen' and a maximum profit was the only goal. In fact
they always argue it is their fiduciary duty to maximize profits
by any means possible!
Doubtlessly, the U.S. Senate will come up with some temporary
'fix' again and this charade of concern for Medicare
beneficiaries will continue until the next time. If the medical
profession had any imagination they would band together to
establish 'not-for-profit' insurance companies or collectives to
offer better reimbursements to doctors and better coverage to
patients - but I won't bet on it in my practice lifetime. At
this point only a total melt-down of the flawed medical
insurance system will likely result in the push for meaningful
change. The next year or two will likely be pivotal in this
process.
At
the New Jersey state level, the NJ Plastic PAC is engaging in a
meaningful dialogue with the new Republican state administration
and Legislature. Important changes are a foot in New Jersey
with proposed 'out-of-network' benefit caps to surgeons. We need
to be at the legislative table the issues are debated, but this
takes money - and lots of it! The NJSPS Board has personally
committed to contributing to the PAC, but it is vitally
important that every member of the NJ Society's donate to the
PAC today. This investment in your practice future will be
repaid many times over in your ability to continue to bill
out-of-network.
Please make a $1,000 contribution to the NJ PlasticPAC by going
to the website --
http://www.njsocietyofplasticsurg.org/pac.html so we can
represent you in this critically important fight in Trenton!
From the Statehouse....Beverly
J. Lynch
On Thursday, March 4, the Assembly Health and Senior Services
Committee invited testimony from the NJ Council of Teaching
Hospitals, who has completed a study of state's physician
workforce needs for the next decade. Deborah Biggs, Senior Vice
President, Health Policy and Advocacy, from NJCTH, reported that
the main problem is that the New Jersey medical school pipeline
is much smaller than neighboring states; half the number of
resident slots by population, and that number is much lower than
the national average as well. This stems, in her opinion, from
the fact that New Jersey medical schools are much younger and
are, therefore, much smaller than older schools. The number of
New Jersey residents that stay in the State to practice is
slowly declining, mainly because they are able to weigh the
options of taxes, cost of living, malpractice insurance, etc.
New Jersey is not a desirable State in which to practice.
Biggs offered a few solutions. The first is for the State to
better organize the work of the teaching hospitals, medical
schools, and residency programs. She suggested establishing a
Medical and Health Workforce planning department to coordinate
stakeholders between the different entities. She also suggested
establishing a re-licensing fee and survey through the Board of
Medical Examiners. This will bring money in to establish the
task force and the survey will supply a more accurate snapshot
of the practicing NJ doctors.
Another suggestion was to provide a tax holiday for physicians
who set up their practice in New Jersey. Since the majority of
those physicians would have set up their practice in other
states, no money will really be lost with the waiving of the
taxation. She recommended support of Assemblyman Conaway's
legislation addressing Medical Malpractice reform in order to
help make New Jersey a less hostile State in which to practice.
Lastly, she suggested that medical schools and teaching
hospitals be rewarded with incentives based upon their graduates
who begin practicing in New Jersey.
Work Begins in Earnest on Priority Physician Initiatives
As expected, hearings have begun on reimbursement rates for
physicians, hospitals and ASCs practicing out of network. A
strong statewide coalition, representing over 20 physician and
hospital organizations, has been formed and begun work to
address the legislative questions as well as proposed budget
changes to the ASC tax.
Heartened by a Republican in the front office, the physician
community is exploring new energy towards some form of medical
liability reform, perhaps in the form of a medical liability
court, or another similar measure.
Legislation Addresses SBME Workload
The Senate has approved legislation, S-1795, sponsored by
Senator Loretta Weinberg (D-Teaneck), that makes various changes
to the membership terms and duties of the State Board of Medical
Examiners (BME).
Specifically, the bill requires that:
-- A member of the BME is eligible for reappointment for one
additional term of office, but no member shall serve more than
two consecutive terms. This limitation shall apply to any member
newly appointed after the effective date of the bill, and any
member serving on the effective date of the bill shall be
limited to two additional consecutive terms.
--To ensure that the BME takes timely disciplinary action to
protect the public, the BME's Medical Practitioner Review Panel
shall investigate notices or complaints it receives from health
care facilities and health maintenance organizations regarding a
licensee in order to make a recommendation to the BME, and make
its recommendation within 90 days after receipt of the
complaint, rather than investigate promptly, as the law
currently provides. If the review panel requires additional time
due to extenuating circumstances, it shall so notify the BME,
indicating the reason and amount of additional time required to
make its recommendation, and transmit a copy of the notice to
the Attorney General and the complainant. The bill also
clarifies that this time-frame is not to be construed to limit
or otherwise impair the BME's authority to take any action
against a licensee or applicant for a license, or the review
panel's authority to make a recommendation.
-- Within 60 days upon receipt of notification from a physician
of any action taken against the physician's medical license by
any other state licensing board or any action affecting the
physician's privileges to practice medicine by any out-of-State
hospital, health care facility, health maintenance organization
or other employer, the BME shall investigate the information
received and obtain any additional information that may be
necessary in order to make a determination whether to initiate
disciplinary action against the physician. The bill also
provides that this time-frame is not to be construed to limit or
otherwise impair the BME's authority to take any action against
a licensee.
The committee amended the bill to delete the provision that
would have required that at least one BME member be a
pediatrician.
From the Third Party Payer
Consultant....James McNally, CPC
Highmark
Medicare Services Releases Guidance on Ordering/Referring
Physician PECOS Issue
Even though the Ordering/Referring Physician PECOS policy has
been delayed until January 2011, it is important that physicians
check to see their status (or lack thereof) in the PECOS system.
As a result, Highmark Medicare Services (HMS) has released an
article that provides guidance to physicians and non-physician
practitioners in determining whether or not they have a current
enrollment record in the PECOS.
To read more, go to the link here:
https://www.highmarkmedicareservices.com/enrollment/pecos/determine.html
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
Medicare Consultation Issue
Synopsis
The Center for Medicare and Medicaid Services (CMS) instructs
that any physician who sees a patient in the office or other
outpatient setting will need to select either a new or
established outpatient evaluation and management code
(99201-99215 or 99381-99397) rather than a consultation code for
Medicare claims.
CMS states that a physician who sees a patient in the hospital
should bill an "initial hospital care" code (99221-99223) for
the first visit for Medicare claims. The admitting physician
will add modifier AI to his/her initial hospital service
allowing the Medicare Administrative Contractor (MAC) to
differentiate between the admitting physician and other
physicians providing care. All physicians should use the
subsequent hospital care codes (99231-99233) for their follow-up
care.
Likewise, CMS states that a physician who sees a patient in a
skilled nursing facility should bill an "initial nursing
facility care" code (99304-99306) for the first visit for
Medicare claims. The admitting physician will add modifier AI to
his/her initial nursing facility care service, allowing the MAC
to identify the physician as the admitting physician of record
who is overseeing the patient's care. All physicians should use
the subsequent nursing facility care codes (99307-99310) for
their follow-up care.
CPT codes 99241-99245 and CPT 99251-99255 have a status
indicator of "I" in the January 2010 National Physician Fee
Schedule. The status indicator of "I" is defined as:
"I" = Not valid for Medicare purposes. Medicare uses another
code for reporting of, and payment for, these services.
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
Empire Blue Cross Blue
Shield Introduces New Claim Research Template Tool
On March 1, 2010, Empire introduced a new tool called the Claim
Research Template (CRT).
EBCBS has indicated that their Physician Network Management team
consists of consultants that focus on ensuring that network
physicians and practitioners understand the processes, policies
and procedures. In addition, this team focuses on informally
researching claim concerns.
As a result, the CRT has been created to ensure that Consultants
have the necessary information to complete informal research on
your claim concerns.
Please note that the CRT does NOT replace the standard claims
grievance process.
It is to be used when physicians and practitioners have concerns
impacting multiple claims and will help facilitate the
collection of certain information so that Empire may conduct
further research, and seek to informally resolve claim issues
raised by providers.
For conditions and other important information, read more at the
link below.
http://www.empireblue.com/wps/portal/ehpprovider?content_path=provider/noapplication/f1/s0/t0/pw_b142772.htm&label=Introducing
a new tool and process to help us better address your claim
questions
CMS Develops Medically Unlikely Edits
(MUE)
The Centers for Medicare & Medicaid Services (CMS) has developed
Medically Unlikely Edits (MUEs) to reduce the paid claims
error rate for Part B (outpatient) claims.
An MUE for a Healthcare Common Procedure Coding System (HCPCS)/current
procedural terminology (CPT) code is the maximum units of
service that a provider would report under most circumstances
for a single beneficiary on a single date of service.
All HCPCS/CPT codes do not have an MUE. Although CMS will
publish most MUE values on their Web site, other MUE values are
confidential and are for CMS and CMS Contractors’ use only.
To view the MUE edits, go to:
http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp
If a physician, healthcare organization, or other interested
party believes that an MUE value should be modified, it may
write Correct Coding solutions, LLC at the address below. The
party should include its rationale and any supporting
documentation.
However, it is generally recommended that the party contact the
national healthcare organization whose members perform the
procedure prior to writing to Correct Coding Solutions, LLC. The
national healthcare organization may be able to clarify the
reporting of the code in question. If the national healthcare
organization agrees that the MUE value should be modified, its
support and assistance may be helpful in requesting the
modification of an MUE value.
Requests for modification of an MUE value should be sent to the
following:
National Correct Coding Initiative
Correct Coding Solutions, LLC
P.O. Box 907
Carmel, IN 46082-0907
FAX: 317-571-1745
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
Legal Report...Kern
Augustine Conroy & Schoppmann, P.C.
President Signs Healthcare Reform Act; NJ Physicians and
State Attorneys General Sue to Stop It
At least fifteen State Attorneys General and at least one
medical society have filed lawsuits against the federal
government, challenging the constitutionality of the new federal
healthcare reform act. The lawsuits were filed within minutes
of President Obama's signing of the bill. The constitutional
challenge is based, in large part, upon Congress' decision to
fine those who fail to purchase health insurance. This is the
first time in the history of our country that the federal
government has mandated that its citizens purchase anything.
Whether the federal government can do so is the question. The
state lawsuits also attack the legislation for creating enormous
additional financial burdens on the states to fund Medicaid. It
is expected that Medicaid rolls will swell under the new law,
when fully enacted, and that the states will bear much of the
associated cost. Physician groups, including a number of state
medical societies, specialty societies and even former
Presidents of the AMA, have voiced strenuous objection to the
new Act, despite its endorsement by the AMA. To date, however,
only one society - NJ Physicians - has taken action to challenge
the bill. Kern Augustine Conroy & Schoppmann, P.C., represents
NJ Physicians in the litigation.
NJ Physicians brought its own lawsuit to address physicians'
concerns about the Act. While applauding those portions of the
Act that address portability, preexisting conditions and greater
insurance coverage, the Act fails to address fundamental flaws
within our healthcare system, including a reimbursement model
that punishes inefficiency. Citing the Mayo Clinic's recent
announcement that it is contemplating no longer accepting any
Medicare patients because it is losing millions of dollars by
treating them efficiently and effectively, NJ Physicians calls
for a restructuring of the reimbursement system. Leaving
physicians with the choice between practicing efficiently and
earning a living will only exacerbate the problem. Without
fixing the reimbursement system and providing tort reform, costs
will continue to rise, insurance premiums will continue to rise,
and rather than improving access to healthcare, the Act may have
the opposite effect.
DHSS Investigating Cases of Infections from Charlatan
Providers
The NJ Department of Health & Senior Services (DHSS) is
investigating six cases of women who suffered infections and
other complications after undergoing cosmetic injections,
apparently administered by unlicensed providers. The Essex
County women had received injections for buttocks enhancement
and were later hospitalized for surgical and antibiotic
treatment at Essex County hospitals. DHSS, in conjunction with
the State Board of Medical Examiners, wants to determine if the
cases are related and learn the identity of the provider(s).
DHSS began receiving reports of the infections in mid-February
and issued an alert through its electronic communications
network, notifying hospitals, physicians, and the statewide
health care community about these cases, the potential for
future cases, and the need to report cases to local and state
public health authorities. DHSS has published a "Cosmetic
Injections FAQs" available on its website at:
http://www.state.nj.us/health/cd/cos_injection.shtml.
Significant Expansion of National Practitioner Data Bank
The National Practitioner Data Bank (NPDB) was established in
1986 as an information clearinghouse to collect and release
certain information related to the professional competence and
conduct of physicians, dentists and, in some cases, other
healthcare practitioners. Effective March 1, 2010, the
so-called "Section 1921" (of the Social Security Act)
regulations expand the information collected and disseminated
through the NPDB to include reports on all licensure actions
taken against all healthcare practitioners, as well as
healthcare entities. Limited querying of the NPDB is now
granted to Quality Improvement Organizations, Federal and State
Healthcare Programs, State Medicaid Fraud Control Units, and
other law enforcement agencies. To learn more about the Section
1921 expansion of the NPDB, go to
www.drlaw.com.
HIPAA/HITECH Implementation Update
The Office for Civil Rights (OCR) has yet to issue a proposed
rule to implement new privacy and security provisions of the
Health Information Technology for Economic & Clinical Health (HITECH)
Act. These provisions include business associate liability, new
limitations on the sale of protected health information,
marketing, and stronger individual rights to access electronic
medical records and restrict the disclosure of certain
information. OCR advises that, although the effective date
(February 17, 2010) for many of these provisions has passed, the
anticipated rule will provide specific information regarding the
expected date of compliance and enforcement of these new
requirements. The new Data Breach Notification rule and new
civil money penalty amounts applicable to HIPAA are effective,
however. Covered entities and business associates must comply
now with breach notification obligations for breaches discovered
on or after September 23, 2009, although OCR used its
enforcement discretion not to impose fiscal sanctions with
regard to breaches discovered before February 22, 2010. A form
of Data Breach Notification policy is on the KACS website at
www.drlaw.com.
President Expands Overpayment Recovery Efforts
On March 10th, President Obama issued a directive expanding the
use of "payment recapture audits" to identify and recover
overpayments. Medicare's Recovery Audit Contractor Program (RAC)
was highlighted by Obama as being particularly successful in
identifying improper payments. The RAC's accounting specialists
and fraud examiners use specialized technology to uncover
overpayments and are compensated on a contingency basis related
to the recoveries obtained. Due to the aggressive nature of the
RACs (because they are paid on a contingency?) and the
substantial exposure that can result from these audits,
physicians should treat a RAC audit as they would an IRS audit,
and consider engaging legal counsel as soon as they are
confronted by a RAC audit. If you are not yet a member of The
Physician Advocacy Program's™ Comprehensive Plan, offered by
Kern Augustine Conroy & Schoppmann, P.C., now may be the time to
join. It includes legal representation if audited by Medicare.
For more information, call KACS at 800-445-0954 and ask for Bill
Czemeris.
Asset Protection: Most Common
Planning Mistakes and Oversights...Dave Vargo, CFP, CMFC
One of the greatest threats to your personal assets is the
potential expense of a long term illness. According to a recent
study done by Genworth Financial (3/2009) the average expense of
providing long term care in central New Jersey is $96,543 per
year. To make matters worse these expenses are increasing, on
average, by about 5.8% every year. The average length of care is
about 4 years; 1 ½ years at home and 2 ½ years in a facility.
Based on these assumptions, in the event of an illness, your
assets could have an exposure of $421,085 today. If these
assumptions hold true your exposure would grow to $739,991 in 10
years and $1,300,418 in 20 years.
The best strategy to protect your assets from this threat is
Long Term Care insurance (LTC). Many of you have taken my advice
and purchased this insurance. And many of you are having your
practice pay the premiums which is the most efficient way to do
it. However, many of you are not taking the income tax
deductions that you are entitled to. If your practice is set up
as an S-Corp, LLC, or PA, the practice pays the premium, takes a
deduction, and passes on the cost of the premium to you as
ordinary income. Your accountant is then supposed to deduct the
premium from your personal tax return. Unfortunately, most
accountants are treating your premiums as ordinary medical
expenses which are not deductible until all of your medical
expenses in aggregate exceed 7.5% of your adjusted gross income
(AGI). For example, if your AGI was $500,000 last year you could
not start deducting your medical expenses until in aggregate
they exceed $37,500. Which, luckily, for most of us, is not the
case. This would be true if you paid for long term care
insurance yourself. However, by having your practice pay your
premiums you are exempt of the 7.5% threshold and premiums are
deductible based on the following age based scale for 2010:
Ages 51-60 $1,230
Ages 61-70 $3,290
Ages 71+ $4,110
So a married couple who are both 61 this year could each deduct
up to $3,290 of their premiums.
For those of you who haven't purchased LTC yet I would strongly
urge you to do so. Many providers are finding that they have
underpriced their policies and as a result will be issuing new
policies with higher premiums (and in some cases decreased
benefits). Now is a perfect time to take advantage of your NJSPS
membership discounts. As a member, you are entitled to exclusive
discounts from many premier providers including Guardian,
Prudential, and John Hancock. Please contact us for addition
information at (877) 972-7900 or
dvargo@varbeco.com.
David J. Vargo, CFP®, CMFC
President, Varbeco Wealth Management,LLC
Announcement: New discounts available to NJSPS members
Your NJSPS membership now entitles you to discounts from several
premier Disability and Long Term Care insurance providers. Both
Union Central and the Standard are offering discounts on not
only their individual disability insurance but also Business
Overhead Expense (BOE) and Disability Buy-Out policies.
Participating Long Term Care insurance providers include
Guardian, Prudential, and John Hancock.
For more information please contact Varbeco Wealth Management at
(877) 972-7900 or
dvargo@varbeco.com.
NJ Life Health & Beauty Magazine
NJ Life Health & Beauty Magazine will be including a guide to
the members of the New Jersey Society of Plastic Surgeons in its
upcoming June/July issue. This is a great opportunity to reach
40,000 affluent health and wellness-minded women.
For advertising/marketing opportunities please call Andy Shane
at 718-549-5910 or e-mail
andy@newjerseylife.com
prior to April 20th.
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