From the President
From the Statehouse
From the Third Party Payer Consultant
From the Legal Counsel
From the President...Gary
Smotrich, MD, FACS
To
My Fellow NJSPS members:
Let me start my first monthly newsletter as NJSPS President by
thanking everyone for the honor of serving as your President for
the next year. We've got a solid organization that's mentioned
in the same breath as the California and Florida societies as
among the strongest state plastic surgery societies in the
country.
I
would again like to thank everyone who attended the annual
meeting in Princeton. Among the most gratifying comments were
from Drs. Hammond and Rubin who I saw at the ASAPS meeting in
Washington. They thoroughly enjoyed coming to Princeton, despite
having to hit the road a few days later for the ASAPS meeting.
Speaking of ASAPS, there was a superb turnout of our New Jersey
members in Washington. Geography is in our favor this year, and
I'm hoping for a similar strong contingent of New Jersey plastic
surgeons in Toronto October 1-5. We're putting the final touches
on a NJSPS event in Toronto. Stay tuned.
We're working on a redesign of the NJSPS website, and Greg Greco
is heading this effort. Paying dues, registering for meetings,
and of course contributing to the NJSPS PAC will all be easier.
Funds from the PAC, which is now headed by Isaac Starker, are
critical this year with our out-of-network reimbursement battle,
and a reinvigorated attempt to get rid of the cosmetic tax. All
PAC contributions are deductible as business expenses.
Finally, membership is what drives any professional society, and
most of us are certainly busy with two national plastic surgery
societies, regional societies and subspecialty organizations.
However, there are too many ASPS members in our state who have
not yet joined NJSPS. Our state society deals with the issues
that hit home, the pocketbook issues that can make or break our
practices. We need as many voices as possible, not only in
Trenton, but throughout the state to keep the plastic surgery
charlatans at bay. If you've got a colleague in your town or
hospital who's not a member of NJSPS, get him or her to join.
We're fighting their battles for free.
Don't hesitate to contact me if you have any questions, issues
or concerns regarding the Society. My office number is
609-896-2525 and my e-mail is
gasmotrich@aol.com.
From the Statehouse....Beverly
J. Lynch
As is tradition, the New Jersey Legislature is on budget break
during the month of April. Every Monday through Thursday,
various commissioners and administration officials appear before
the Assembly and Senate Budget Committees for presentations of
their budgets and questions from the legislative members.
Of most import to the physician community would be the testimony
and questioning of the Commissioner of Health and Senior
Services, and the Commissioner of Banking & Insurance,
especially in light of the fact that these individuals are new,
and the new Administration brings their own set of priorities
and issues. Obviously, most of the testimony has focused on
budget cuts, with all departments charged with cuts in services
and programs. For those physicians with time of your hands, and
a passion for politics, you can listen to these hearings on
http://www.njleg.state.nj.us/ and click on "archived
proceedings."
Organized medicine continues its work on addressing the attacks
on out-of-network reimbursement, and the proposed increase on
the ASC tax (by removing the cap currently in place). A strong
coalition representing 22 physician groups has been formed and
tasks assigned.
From the Third Party Payer
Consultant....James McNally, CPC
Congress Postpones
Medicare Fee Reductions Yet Again!
This Time until June 1, 2010
As reported previously, the 21.2 percent cut in Medicare fees
has technically been in effect since April 1, 2010.
However, no payments were made at this drastically reduced rate
as the Center for Medicare and Medicaid Services (CMS) had
ordered their contractors to hold all claim payments until April
14, 2010.
In the meantime, Congress passed, and the President approved, an
extension bill on the evening of April 15, 2010 that postpones
these draconian cuts until June 1, 2010.
It is possible (but not likely) that some claims for physician
services may have been processed on April 15, 2010 at rates
reflecting the 21.2 percent cut. Highmark Medicare has stated
that no claims were processed at the reduced rate.
However, CMS has reiterated that any such claims will be
reprocessed and payment adjustments made without physicians
having to take any additional action.
In any event, all claims that were held will be released for
payment.
Please keep in mind that the statutory payment floors still
apply and, therefore, clean electronic claims cannot be paid
before 14 calendar days after the date they are received by
Medicare contractors (29 calendar days for clean paper claims).
Physician practices should continue to submit claims using the
Fee Schedules presently posted on the MAC web sites.
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
United Healthcare UCR
Settlement Documents are on the Way
A record breaking settlement has been reached in organized
medicine’s action against United Healthcare (UHC) and their use
of artificially low payments via their UCR fee schedules in the
payment for out of network services to physicians.
More than $350 million is available to compensate physicians and
their patients for 15 years of artificially low payments for
these out-of-network services.
The deadline for filing a claim to share in the settlement fund
is October 5, 2010. The settlement claims administrator began
mailing the settlement notice and claim forms to physicians on
April 16, 2010.
Physicians should be on the lookout for a plain white mailer
with “United Healthcare” written on the bottom and with the
return address referencing the Settlement Claims Administrator:
United Healthcare Class Action Litigation c/o Berdon Claims
Administration LLC, P.O. Box 15000, Jericho, NY 11853-1001.
In order to assist you in this effort, the American Medical
Association (AMA) is providing a new on-line resource that will
help affected physicians with step-by-step guide to and help in
determining eligibility, assembling documentation and filing a
claim under the terms of the settlement.
Go to the link here and read more about what needs to be done in
regard to this record-breaking settlement reached in the AMA’s
legal victory against UnitedHealth Group—the nation's largest
health insurer and parent company of UHC.
http://www.ama-assn.org/ama/pub/advocacy/current-topics-advocacy/private-sector-advocacy/health-insurer-settlements/unitedhealth-ucr-settlement.shtml
AMA physician members can also get personal assistance with
filing a claim by going to the AMA Practice Management Center at
the link here or by calling (800) 621-8335.
http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/practice-management-center.shtml
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
Health First to Cut Reimbursements
Effective July 2010
In what may be a trend in the industry in the coming months,
Health First has announced a reimbursement cut in payments to
physicians effective July 1, 2010.
A letter dated April 1, 2010 has been sent out announcing these
cuts along with instructions on how to resign from the plan if
the practice chooses to exercise their termination rights under
their contract. The letter also follows the state law that
requires that physicians be given 90 days notice of any adverse
reimbursement change.
A sample of the planned fee cuts along with the procedure codes
was sent along with this letter.
If you are no longer able to work within these payment
constraints, your termination or resignation letter from Health
First should be sent to the following address. You may also fax
it to the number listed below.
Health First
Provider Services
PO Box 5168
New York NY 10274-5168
Fax: 1 646 313 4634
Changes made to Timely
Filing Requirements for Medicare Fee-For-Service Claims
On March 23, 2010, President Obama signed into law the
Patient Protection and Affordable Care Act (PPACA), which
amended the time period for filing Medicare fee-for-service (FFS)
claims as one of many provisions aimed at curbing fraud, waste,
and abuse in the Medicare program.
Under the new law, claims for services furnished on or after
January 1, 2010, must be filed within one calendar year after
the date of service.
In addition, the law mandates that claims for services furnished
before January 1, 2010, must be filed no later than December 31,
2010.
The following rules apply to claims with dates of service prior
to January 1, 2010.
-
Claims with
dates of service before October 1, 2009, must follow the
pre-PPACA timely filing rules.
-
Claims with
dates of service October 1, 2009, through December 31, 2009,
must be submitted by December 31, 2010.
The PPACA also permits the Secretary to make certain exceptions
to the one-year filing deadline.
However, at this time, no exceptions have been established.
However, proposals for exceptions will be specified in future
proposed rulemaking.
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
PPACA Calls for
Disclosures when Performing Certain Imaging Services for
Medicare Patients
The Patient
Protection and Affordable Care Act (PPACA) (H.R. 3590), recently
signed by the President, contains a number of onerous
requirements that impact medical practices that provide CT, MRI
or PET to Medicare patients. This new policy is also known as
the Medicare in-office ancillary exception regulation.
You must now
provide the following disclosures to your Medicare patients:
-
Inform the
patient in writing at the time of the referral that the
individual may obtain the ordered services from a person
other than the ordering physician or another physician in
the group.
-
You are then
required to provide the patient with a list of providers of
the service who are located within the area in which the
patient resides. The law, however, provides no guidance on
what this list should look like or what must be included).
If you fail to
provide the proper disclosure to the patient and to provide the
list of alternative providers, the service is non-reimbursable
and physicians who submit non-reimbursable claims have potential
exposure under the federal False Claims Act.
CMS Issues Alert on Identity
Theft Warning
AdvanceMed, the
Program Safeguard Contractor for Part A Medicare in Ohio,
Kentucky, and Minnesota and for Part B in Ohio and Kentucky,
would like to share some important information related to
provider identity theft. In October of 2008, a scheme was
identified by Cahaba Government Benefit Administrators related
to provider identity theft. Since that time, another scheme of
the same type has recently been identified by Noridian
Administrative Services in Minnesota.
The scheme works
as follows: the provider who is the potential victim will
receive a legitimate looking facsimile from their carrier’s
provider enrollment department. The request is posted on
counterfeit letterhead from the carrier. The letter states that
the carrier is updating their provider enrollment file and
demands a response from the physician within 48 hours or they
will experience a disruption in their payments. The individuals
involved in this scheme are not employed by the carriers.
Although this
scheme has not been detected in the states of Ohio and Kentucky,
AdvanceMed suspects that these identity theft perpetrators will
repeat this scheme in our jurisdiction. Additionally, it has
been found that several providers have had their identities
stolen when they applied for fictitious jobs. Once an
application is submitted by the provider, the perpetrators have
everything required to start billing as the victimized provider.
AdvanceMed
encourages the following steps to be taken in order to help in
identity theft protection:
-
Shred all
sensitive documents
-
Do criminal
background checks when hiring new employees
-
Monitor any
correspondence that leaves your office outbound for Medicare
and other insurance companies
-
Protect your
own information in the same way that you protect your
patients’ information
-
If you receive
a request from the carrier for a provider enrollment update
via facsimile, call the carrier to confirm that it
originated with them. Do not use the phone number listed on
the facsimile transmittal
-
When applying
for new positions, do extensive research about your
potential employer before giving out personal information
-
Do not post
your resume that includes identifying provider numbers on
the Internet
-
Educate your
staff members regarding the importance of protecting your
provider information
If you suspect
that you have been the victim of identity theft, contact the
carrier immediately.
Visit the Web site
http://www.ftc.gov/bcp/edu/microsites/idtheft/ published by
the Federal Trade Commission for more information on identity
theft.
Empire Blue Cross Blue
Shield Releases April 2010 Provider Newsletter
Changes to Consultation Billing and Other Topics Are Highlighted
Empire Blue Cross
Blue Shield (EBCBS) has released the April 2010 edition of their
Provider Newsletter.
This issue
contains important information on consultation billing for
certain products, changes to their managed care referral form,
and other topics that are important to your treatment of EBCBS
subscribers.
To read more, go
to:
http://www.empireblue.com/provider/noapplication/f5/s1/t2/pw_b144120.pdf?refer=ehpprovider
Medicare Advantage Fraud,
Waste, and Abuse (FWA) Training no longer Mandatory
As reported
previously and expected, the Center for Medicare and Medicaid
Services (CMS) has published a rule about Medicare Advantage and
Part D plans requiring that physicians take a formal course on
an annual basis in Fraud, Waste and Abuse (FWA) training.
The rule
explains that physicians and suppliers, by virtue of their being
enrolled in the Medicare program do not need to obtain fraud,
waste and abuse-compliance training from Medicare Advantage
plans.
For guidance on
this issue, contact us through the Third Party Insurance Help
Program.
Legal Report...Kern
Augustine Conroy & Schoppmann, P.C.
NJ Supreme Court Refuses to Review ASC Case
As previously reported late last year, a New Jersey appellate
court upheld a trial court's ruling in Garcia v. Health Net
that the physician owners of an ambulatory surgery center (ASC)
did not engage in insurance fraud when they referred their
patients to the center which was set up in line with prior NJ
State Board of Medical Examiners' advisory letters. That court
also upheld the trial court's determination that, in certain
situations, the center in Garcia could waive patients'
co-pays without fear of being charged with insurance fraud. The
NJ Supreme Court has now refused to hear Health Net's appeal of
that appellate decision, which means the trial court's decision
is now the final word in the Garcia case. As an
"unreported" decision, it is of limited precedential value, and
last year's amendments to the Codey law now moot much of the
decision's impact going forward, although the Garcia
decision may be used effectively to thwart carrier efforts to
avoid paying centers for fees predating the Codey amendments. As
for co-pays, caution must be urged. Garcia does not
permit the universal waiver of co-pays or the advertising of
such a policy. If a center's ownership is considering
instituting a policy involving a waiver of co-pays, they should
seek legal counsel, particularly since legislative efforts would
severely restrict such waivers. Perhaps the most important
impact of the Supreme Court's rejection of Health Net's appeal
will be on the insurance industry's belief that it could get
away with anything in this State, hopefully signaling greater
judicial scrutiny of insurance industry cases. The State's
carriers, with the tacit support of the courts, have long
behaved as if merely accusing a center or a physician of
insurance fraud was enough to avoid their financial obligations.
Now the carriers know there are limits to that strategy. For
more information on how the Garcia decision or the Codey
law amendments may affect your practice or ASC, contact KACS's
Bob Conroy at conroy@drlaw.com
or 908-704-8585.
FTC Enforcement of the Red Flags Rule to begin June 1st
As
of today's date, the Federal Trade Commission has not taken
action to delay enforcement of the Red Flags Rule nor to exempt
physician practices from the Rule. The Red Flags Rule, scheduled
to be enforced effective June 1, 2010, requires covered entities
to implement an identity theft prevention program. While many
efforts are underway to challenge the application of the Red
Flags Rule to physician practices and small health care
facilities, New Jersey law already requires identity theft
prevention. Physicians who have not yet developed an identity
theft prevention program in conformance with the Red Flags Rule
and applicable state law can find an Identity Theft Prevention
Program template at www.drlaw.com,
to adapt to their practice.
Decreasing Medicare Rates May Lead to Shortage of Medicare
Physicians
The recurring reduction in Medicare payment rates has resulted
in frustration among physicians who treat patients covered by
the plan. Increasingly, practitioners who can afford to absorb
the lost revenue are "boycotting" Medicare, effectively shunning
the antiquated Medicare rate methodology whereby reimbursement
rates are adjusted annually according to the health of the
national economy. As the plan is poised to accept an additional
seven million "baby boomers" to its beneficiary roll over the
next 5 years, the risk that there will be a shortage of
physicians accepting Medicare patients is high. Physicians have
options when reducing their Medicare load: keep existing
Medicare patients but close their practice to new Medicare
patients; stop serving Medicare patients altogether; choose
non-participation status; or opt out of Medicare and contract
privately with Medicare patients. Specific rules and timeframes
apply, including state laws governing the termination of the
physician-patient relationship.
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