Archive | June 2013

Medicaid Agrees to Retroactive Payment to January 1

Medicaid has agreed to pay certain resubmitted claims retroactive to January 1 in response to an MSNJ request. In January 2013, the Medicaid program required that all physicians who order, refer, or attend Medicaid beneficiaries, but do not bill for their services, enroll in the program as non-billing providers. The program confirmed to MSNJ that enrolling will not cause a physician to become a participating provider, but it will allow participating providers to be paid and will bring the program into compliance with the Affordable Care Act.

MSNJ subsequently received complaints from Medicaid participating providers who are not being paid due to the ordering/referring physician’s failure to enroll as a non-billing provider. In April MSNJ requested that the Medicaid program “consider making an exception that allows for resubmission of claims for payment once the non-billing provider has enrolled.”  The program recently advised that the treating physician may resubmit denied claims after the ordering/referring physician enrolls as a non-billing provider.

In 2013, non-billing provider enrollment will be retroactive to January 1, 2013. In 2014 and going forward, non-billing provider enrollment will be retroactive to one year prior to receipt of the enrollment application. For instance, a non-billing provider who submits an enrollment application on March 15, 2014 will be retroactively enrolled back to March 15, 2013. This is to allow participating physicians enough time to resubmit claims within the timely filing limit (up to one year).

MSNJ appreciates the Medicaid program’s response to our request.

US Supreme Court Allows Class-Arbitration for Physicians: Agrees with Arguments Advanced by MSNJ and AMA

On June 10, the United States Supreme Court found that the Oxford participation agreement’s arbitration clause allowed payment disputes to be pursued by physicians as a class. Over a decade ago Oxford had compelled  Dr. John Sutter, a New Jersey pediatrician, to arbitrate his payment disputes, but challenged his right to arbitrate the disputes with other physicians similarly situated as a class. The arbitrator ruled that a class arbitration was appropriate as did each court that reviewed the matter. Undeterred, Oxford took the case all the way to the US Supreme Court. MSNJ and the AMA filed friends-of-the-court briefs supporting the physicians’ right to class arbitration.  Now, the highest court in the land has agreed.

This is an example of success by MSNJ’s legal advocacy program.

American Board of Medical Specialties under Fire for Maintenance of Certification™ Program

Criticism of the American Board of Medical Specialties’ (ABMS) Maintenance of Certification™ (MOC) program has escalated over the past year. This has manifested in a number of ways. A national specialty society and at least two states have introduced resolutions that will be heard by the AMA; one national association has filed a lawsuit.

The AMA has already developed a number of policies on maintenance of certification and maintenance of licensure issues which address the cost, disruption to practice, and possible negative impact on access to care. In response to a joint resolution introduced by Camden, Mercer, and Passaic counties, the MSNJ Board of Trustees considered a resolution during its meeting on Sunday, June 2. After extensive testimony from the proponents of the resolution, county leaders, board members, and fellows, the Board took action on the resolution. It referred part of the proposed resolution back to the Policy and Strategy Panel and  adopted the following concepts:

  • Acknowledging that certification requirements within the Maintenance of Certification™ can be costly, time intensive, and result in significant disruptions to the availability of physicians for patient care;
  • Requiring MSNJ to communicate to the AMA and the ABMS examples of disproportional fees, onerous time requirements and unnecessary fragmentation of commonly recognized specialties; and
  • Opposing Maintenance of Certification™ in its present form, but reaffirming the need for ongoing CME to meet the AMA Physician’s Recognition Award and demonstrating the commitment to quality patient care.

The MSNJ delegation to the AMA will be guided by the discussion that took place during the Board meeting for its deliberations on the similar resolutions that will be considered at the AMA Annual Meeting in Chicago this month.

On a different tack, the American Association of Physicians & Surgeons filed a lawsuit in the New Jersey Federal District Court against the American Board of Medical Specialties alleging that its Maintenance of Certification™ program violates federal antitrust laws and that its statement about physician’s status in terms of maintenance of certification are misleading.