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UHC Terminations of Physicians in Medicare Advantage Plan

In mid-October UHC began terminating physicians in their Medicare Advantage plan. We immediately reached out to UHC when it appeared that the terminations were not isolated, but rather part of a   broad initiative. This week, UHC responded to some of our questions. We are disappointed that there was no warning of this termination initiative which appears to be a significant redesign of the UHC Medicare Advantage network, nationwide, and that information is sparse. For example, UHC would not tell us how many physicians in New Jersey were terminated or whether any specialties were immune to the termination initiative. Yet, UHC assured us that the network had been “tested and retested” for network adequacy and that there would not be a specialty access issue.

Network Adequacy: Obviously, MSNJ has no way of evaluating the impact on the network without more information. Therefore, we are asking all physicians who received termination letters, to provide us with information so that we can better evaluate network adequacy concerns. CMS has agreed to help us with that assessment.

Lack of Transparency: In addition to our network adequacy concerns, we are troubled that patients may be enrolling or re-enrolling in the UHC Medicare Advantage plan now, because seniors are in the middle of open enrollment, believing that they will be able to continue to be treated by physicians who are currently in the plan. UHC agreed to consider our complaint on lack of transparency on the 2014 network, given that seniors are enrolling now based on the current network. It is important to note that patients may change their network selection. CMS will honor the last selection made by the patient by December 7 when open enrollment ends.

Continuity of Care: We expressed our concerns about continuity of care and a disruption of established physician-patient relationships.  We urged UHC to carve out an exception for patients who wish to continue to see their current physician. UHC agreed to consider this request. We believe that patients should have the right to choose their physicians and must know their network status to make those choices.

Discussions with CMS: With a reopening of the federal government, we have contacted CMS about our network adequacy and continuity of care concerns. Our Region 2 office has been facilitating communication with the Region 9 office which is responsible for the UHC Medicare Advantage network. CMS Region 9 is charged with ensuring network adequacy and transparency for Medicare beneficiaries in their selection of a Medicare product. CMS has offered to test areas for network adequacy. Please provide us with information so that we can identify geographical and specialty areas of concern.

What to do: Last week we urged physicians who wished to stay in the Medicare Advantage network to appeal and provided suggestions for those appeals. We will continue to update our advice to members as more information becomes available to us.  Visit our web site for a list of Do’s and Don’ts, Appeal Suggestions, a template letter to inform patients of your imperiled status in the UHC Medicare Advantage Network.

Visit MSNJ’s UHC Webpage for more information.

Save the date for MSNJ’s UHC Termination Update webinar on Tuesday, October 29 at 7:00PM. Details to follow on

MSNJ Legislative Update: May 10, 2013

Pediatric Respite Care Facilities

The Assembly Regulated Professions Committee unanimously approved A. 3558 which will provide a license for pediatric respite care facilities.  A pediatric long-term care facility is not required to seek a dual license under this bill.  MSNJ took no position on this bill, but recognizes its potential to help families deal with pediatric illnesses.

Mental Health Coverage for Alcoholism & Substance Abuse Disorders

The Assembly Health Committee passed A. 1665/S. 1253, which would revise statutory mental health coverage requirements and require all health insurers and SHBP to cover treatment for alcoholism and other substance-use disorders under the same terms and conditions as for other diseases or illnesses. MSNJ has supported mental health parity measures, including this one, for years. The bill is particularly important in light of the focus on mental health issues related to gun violence.

Influenza Vaccinations for Healthcare Workers

The Assembly Health Committee passed A. 2172, which would require that a healthcare facility annually offer on-site or off-site influenza vaccinations to its health care workers, and they would be required to receive an influenza vaccination, but would be permitted to present acceptable proof, including an attestation by the health care worker, of a current influenza vaccination from another vaccination source, or sign a written declination statement. The bill is poised for full votes in both houses; the Governor vetoed the bill last year. MSNJ supports the bill.

Prescription Drug Donation Repository Program

The Assembly Health Committee passed A. 2188/A. 3964, which would establish a prescription drug donation repository program in the Department of Health (DOH).  This program will provide for the donation of unused prescription drugs and supplies by persons, health care facilities, and pharmacies to a central repository for redistribution to authorized medical facilities and pharmacies in order to re-dispense these medications, which would otherwise be destroyed, for use by individuals who meet eligibility criteria specified by the Commissioner of Health. MSNJ supports the bill, as it is in line with our goal to reduce abuse and diversion of drugs, particularly opioids.

Limitation of Settings for Certain Surgeries

The Senate Health Committee approved S. 2079, sponsored by Senator Richard Codey, which would limit settings where certain surgeries may be performed.  Under the bill, a physician may only perform any of the following procedures in an office or facility that is accredited by the American Association for Accreditation of Ambulatory Surgery Facilities, the Accreditation Association for Ambulatory Health Care, or The Joint Commission: a liposuction procedure that involves more than 750 cubic centimeters of aspirate; a procedure that utilizes a breast implant; or an aesthetic truncal contouring procedure that involves the excision of skin. This bill is supported by plastic surgeons, but opposed by dermatologists. MSNJ opposes the bill on the principle that clinical matters of such specificity should not be legislated.

Medicaid Expansion

The Senate Health Committee also passed S. 2644, sponsored by Senators Joseph Vitale, Nia Gill and Loretta Weinberg, which would expand Medicaid eligibility pursuant to the federal Affordable Care Act.  The bill essentially is the legislative version of the Governor’s decision to expand Medicaid eligibility under the ACA.  MSNJ’s position on expansion can be found here.

Value Based Benefit Design for Chronic Health Conditions

The Assembly Appropriations committee passed A. 1214, which establishes a pilot program to utilize value-based benefit design in the State Health Benefits Plan to increase health benefits coverage for certain employees concerning chronic health conditions.  The coverage design will utilize explicit financial incentives to increase the employee’s interaction with appropriate health care providers, and encourage use of those health benefits that specifically relate to the employee’s chronic health condition.  MSNJ is monitoring this bill, which mirrors the goals of ACOs and other new payment models that focus on outcomes.

Health Benefit Mandate for Breast Imaging Services

The Assembly Appropriations committee also passed A. 2022/S. 792, which contains an insurance mandate for certain tests following mammograms and requires certain notice about risk factors. 

The bill requires health insurers to provide health benefits coverage for additional testing deemed medically necessary by a patient’s health care provider, of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer.  Additional risk factors include, but are not limited to, family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System, or other indications as determined by the patient’s health care provider. The bill also requires providers of mammography services to include information on breast density in mammography reports sent to patients and physicians, if a patient’s mammogram demonstrates extremely dense breast tissue based on the Breast Imaging Reporting and Data System.  The bill provides that the information on breast density must include the following statement:  “Your mammogram shows that your breast tissue is extremely dense as determined by the Breast Imaging Reporting and Data System established by the American College of Radiology.  Dense breast tissue is very common and is not abnormal.  However, extremely dense breast tissue can make it harder to find cancer on a mammogram and may also be associated with a risk factor for cancer.  This information about the result of your mammogram is given to you to raise your awareness.  Use this information to talk to your health care provider about this and other risks for breast cancer that pertain to your personal medical history.  A report of your results was sent to your physician.”

MSNJ was engaged in improving the bill along with radiology and ob/gyn specialty societies, so that it reflects clinical realities and current practices.  Insurance providers and business groups oppose the bill.

MSNJ Legislative & Regulatory Update – March 22, 2013

From Trenton: Assembly Action:
On Thursday, the Assembly passed a bill that requires physicians to complete survey as condition for biennial registration with Board of Medical Examiners and requires board to maintain and disseminate survey data as appropriate. S. 1336 aims to address workforce shortages and now heads to the Governor’s desk.

The Assembly on Thursday voted on S. 2082, the “Opioid Antidote and Overdose Prevention Act,” which provides immunity from civil and criminal liability and professional discipline for health care professionals who prescribe or dispense naloxone or any similarly acting drug approved for the treatment of an opioid overdose. It provides immunity from civil and criminal liability for other persons who administer such a drug in an emergency to an individual who the person believes in good faith is experiencing an opioid overdose. A health care professional prescribing or dispensing an opioid antidote to a patient would be required to ensure that the patient receives overdose information, which is specified in the bill, and could fulfill this requirement by maintaining a written agreement for the provision of such information with a community-based organization, substance abuse organization, or other organization which addresses medical or social issues related to drug addiction.  MSNJ and the AMA support this bill.

Senate Action:

The Senate passed mental health parity legislation on Monday. S. 1253, sponsored by Chairman Vitale, requires SHBP and SHEBP to cover treatment for alcoholism, other substance-use disorders, and non biologically-based mental illnesses under same terms and conditions as for other diseases or illnesses. MSNJ supports this bill. The Assembly has not yet considered the bill.

Also on Monday, the Senate passed A. 3080, sponsored by Chairman Schaer, which requires health benefits coverage for refills of prescription eye drops under certain conditions. MSNJ supports this bill which now heads to the Governor’s desk.

Gubernatorial Action:

This week, Governor Christie signed a scope of practice bill that MSNJ worked on intimately.  S. 555 removes from a genetic counselor’s scope of practice interpreting such laboratory tests and other diagnostic studies and clarifies that genetic counseling includes identifying, coordinating, and explaining the clinical implications of genetic laboratory tests and other diagnostic studies and their results.  The bill also adds to the scope of practice integrating genetic laboratory test results and other diagnostic studies with personal and family medical history to assess and communicate risk factors for genetic or medical conditions and diseases.  Current law provides that the provisions of the “Genetic Counselor’s Licensing Act,” shall not apply to a person licensed by the State to practice medicine and surgery when acting within the scope of the person’s profession and doing work of a nature consistent with the person’s training, so long as the person does not hold himself out to the public as a genetic counselor.  The bill provides that the act shall not apply to a person licensed by the State to practice medicine and surgery, so long as the person does not hold himself out to the public as a licensed genetic counselor.

New Jersey’s Fiscal Year 2014 Budget

The Legislature has begun its budget hearings, taking testimony from members of the public. In the Assembly hearing on health issues, over 30 people testified with concerns on funding for hospitals, mental health programs and other items.  MSNJ will remain engaged in the budget process, particularly Medicaid Expansion. Read MSNJ’s policy statement on Medicaid expansion.

From Washington: House Committees Continue their Work on SGR Repeal & Replacement
The AMA recently provided in-put to the House Committees on Ways & Means and Energy & Commerce proposal to repeal Medicare’s flawed sustainable growth rate (SGR) formula and replace it with physician-driven quality and payment methodologies. Key points included:

  • Phase I: Permanent repeal of the SGR and statutorily-defined rates based on the Medicare Economic Index (MEI) for three to five years
  • Phase II: Fee schedule updates based on meaningful, physician-endorsed measures of care and clinical improvement; reduced reporting burdens; timely access to quality performance scores
  • Phase III: After several years of risk-adjusted quality-based payments, physicians who perform well would earn additional payments based on efficiency; duplicate programs and reporting requirements would be eliminated.

Other in-put included:

  • a “Provider Shield Act” so that reporting would not be used as evidence in tort actions;
  • private contracting without penalty to physicians and patients to ensure patient choice and access to care.

Health Information Technology (HIT) – President’s Message: June 26

By Dr. Mary Campagnolo, MSNJ President

According to the United States Department of Health and Human Services/Office of the National Coordinator for Health Information Technology, health information technology (health IT) makes it possible for health care providers to better manage patient care through secure use and sharing of health information.

Health IT includes the use of electronic health records (EHRs) instead of paper medical records to maintain people’s health information.

Improving Patient Care

With the help of health IT, we as health care providers will have:

  • Accurate and complete information about a patient’s health. That way we can give the best possible care, whether during a routine visit or a medical emergency.
  • The ability to better coordinate the care we give. This is especially important if a patient has a serious medical condition.
  • A way to securely share information with patients and their family caregivers over the Internet, for patients who opt for this convenience. This means patients and their families can more fully take part in decisions about their health care.
  • Information to help doctors diagnose health problems sooner, reduce medical errors, and provide safer care at lower costs.

Improving Our Nation’s Health Care System

Widespread use of health IT can also:

  • Make our health care system more efficient and reduce paperwork for patients and doctors.
  • Expand access to affordable care.
  • Build a healthier future for our nation.

For one-stop access to information on health IT from the U.S. Government visit

Health Insurance Exchange Dominates Early Healthcare Politics

The 215th legislature barely came to order last month before the Assembly Health and Senior Services Committee had scheduled Health Insurance Exchange legislation for a vote.  The bill, A-2171 (Conaway, D – Burlington), would create a Health Insurance Exchange (HIX) in, but not of, the Department of Banking and Insurance, meaning its Board of Directors would be free to act independently of the DOBI Commissioner.  Committee amendments would create a separate advisory panel consisting of provider and payer representatives to assist the board in its operations.  Once established, the exchange will provide a one-stop marketplace for purchasers of small employer and individual health benefits and it could help better spread risk.

The most contentious issue in the HBE debate thus far is over the matter of “active purchasing” versus “passive purchasing.”  Both A-2171 and its Senate counterpart S-1319 (Gill, D – Essex), provide for active purchasing, meaning the Board can decline applicant insurers the ability to sell products through the Exchange.  Proponents of passive purchasing argue that meeting state and federal requirements should be sufficient to qualify for access to the exchange.  MSNJ is currently supporting active purchasing, provided that proper measures are adopted to prevent larger insurers from exploiting the exchange to further consolidate market power.

According to the Affordable Care Act, states must have certified HIX operational by 2014, or delegate that authority to the federal exchange.

Conferees reach agreement on short-term SGR patch; AMA & MSNJ express deep disappointment

A message from the AMA:

While some details are still being finalized, it is being reported from Capitol Hill that conferees have reached agreement on extending the payroll tax holiday, unemployment insurance benefits, and current Medicare physician payment rates for the next 10 months, through the end of 2012.

In lieu of the 27.4 percent physician payment cut scheduled to take effect on March 1, a payment freeze will be effective through the end of the year.  The cost of this short-term patch was reportedly offset through reductions in a number of health care programs, including Medicaid disproportionate share payments to hospitals, Medicare bad debt payments to hospitals, federal Medicaid payments to Louisiana, and the prevention fund created by the Affordable Care Act.  Other expiring Medicare policies were also extended through the end of the year, including the “floor” on geographic adjustments to the physician work component of the Medicare fee schedule, the therapy cap exemption process, and ambulance add-on payments.  Two policies—Section 508 hospital and special pathology payments—will be phased out, and mental health add-on payments and pay increases for bone density scans have been eliminated.

Assuming this agreement secures sufficient support, it could be voted on by both the House and Senate by the end of the week.

The AMA issued the following statement as details of this agreement began to emerge, attributable to AMA President Peter W. Carmel, MD:

“The House and Senate conference committee agreement averts a 27 percent cut on March 1, but it represents a serious missed opportunity to permanently replace the flawed Medicare physician payment formula and protect access to care for military families and seniors. People outside of Washington question the logic of spending nearly $20 billion to postpone one cut for a higher cut next year, while increasing the cost of a permanent solution by about another $25 billion.

 “Congress had an opportunity to permanently end this problem, which is the sound, fiscally prudent policy choice. We appreciate efforts by members of Congress on both sides of the aisle who publicly supported a framework for a permanent end to this perennial problem. We are deeply disappointed that Congress chose to just do another patch – kicking the can, growing the problem and missing a clear opportunity to protect access to care for patients. Shortly after the coming elections, access to care for seniors and military will again be threatened by an even larger cut, and members of Congress will need to take swift action to end the broken formula.”

MSNJ Meets with Congressman Pallone on the Repeal of SGR

This week, Larry Downs, MSNJ’s CEO and General Counsel, met with Congressman Frank Pallone to discuss a repeal of Medicare’s sustainable growth rate (SGR) which results in annual Medicare fee decreases to physicians. Congressman Pallone is a member of the Energy & Commerce Committee, and Ranking Member of the Health Subcommittee which shares jurisdiction over Medicare with the Ways & Means Committee.  We are pleased to report that Congressman Pallone supports our efforts to repeal the SGR. Read MSNJ’s letter to Congressman Pallone.

MSNJ, the AMA, and organized medicine are urging Congress to seize upon this historic opportunity to use funds in the Overseas Contingency Operations (OCO) to pay for the elimination of the SGR. OCO is the discretionary fund for Afghanistan, Iraq and similar conflicts. Using OCO funding as an offset is appropriate because these conflicts are winding down significantly, but the Congressional Budget Office cannot downwardly adjust the OCO spending estimate over the next ten years until the next (FY2012) Defense Appropriations bill is passed. Read more about the rationale to use OCO funds to offset the SGR elimination which would pay for the accumulated cost of repeal. The current cost is approximately $300 billion. Congressman Pallone agrees that using OCO funds is an appropriate solution and will advocate for this. On behalf of physicians at large and our members who treat our senior population, we express sincere thanks for this support.

MSNJ also signed a letter authored by the AMA to members of the conference committee on payroll taxes, unemployment insurance and physician payments, urging it to repeal the SGR. The AMA reports that during the first public meeting on January 24 virtually all statements addressed the payment crisis and several members called for the permanent repeal as part of the final conference committee package. MSNJ will continue to meet with our delegation. Meetings with Congressmen Leonard Lance (R-NJ, 7th district) and Jon Runyan (R-NJ, 3rd district) have already been scheduled.

UHC Announces Changes to its Medicare Advantage Audits

Thanks to the efforts of the AMA, its federated members and a number of our sister state medical societies, United Healthcare (UHC) has agreed to make several changes to the way that it conducts its Medicare Advantage audit programs.

UHC will no longer use MedAssurrant, the contractor that previously conducted its payment integrity audits. UHC will also make changes in the way that it conducts its Risk Adjustment Date Validation (RADV) audits. These audit request letters will be more clear about the reason for the audit and provide consistent information on follow-up medical record review, audit requests, and post-audit claim payment determinations. UHC will also update its payment integrity and recovery practices. Currently, UHC asks physicians to refund the full amount paid on the original claim and then resubmit the claim using the recommended coding. In the first quarter of 2012 physicians will only need to resubmit the claim with the recommended coding and refund only the difference between the amount UHC originally paid and the amount that should have been paid using the new coding. Physicians who disagree with UHC’s recommended coding should appeal the claims.

Many of our members have complained of the audit practices and we have been able to help them refine the scope of the audit. We appreciate AMA and organized medicine’s efforts to achieve systemic change on this issue.

Christie Administration Recognizes the Need to Reduce Regulatory Burdens for Medical Practices

This week, in response to the efforts of MSNJ, the Christie Administration acknowledged in a press release the need to reduce regulatory burdens on physicians to bend the cost curve of healthcare delivery in New Jersey. The administration’s Department of Banking & Insurance (DOBI) Commissioner, Tom Considine, and key members of his staff visited the medical practices of five MSNJ members to observe first-hand the challenges of meeting administrative requirements imposed by insurance carriers. MSNJ President Niranjan (Bonki) Rao expressed the thanks of the organization for DOBI’s interest in how physician practices operate and for an ongoing dialogue.

Commissioner Considine indicated that the visits were an “eye opening” learning experience to see the administrative side of medical practices. He further indicated that he felt that improvements could be made. Commissioner Considine stated that:

Our healthcare providers are on the front line of the healthcare system and as such we value them very deeply. . . . My goal is to work with them and our insurance carriers to do whatever we can to bring down the costs of healthcare.  We are all looking for ways to achieve maximum efficiency in the system and that means all parties must work together to eliminate unnecessary steps. 

The DOBI press release noted recent efforts to reduce the administrative burden of medical practices, including: a new regulation allowing obstetricians to elect installment payments instead of a global payment for maternity services; a bulletin to remind insurance carriers that once services are preauthorized they must be paid for except in cases of fraud; and forums on the implementation of exchanges under the Affordable Care Act.

DOBI also noted other areas under review, including: strengthening provider agreements; improving the credentialing system; clarifying the reimbursement system; and improving provider directories. MSNJ has been engaged in ongoing efforts on these issues.

MSNJ’s CEO expressed the organization’s pleasure in coordinating DOBI’s efforts to observe the administrative hurdles that physician practices face on a day-to-day basis. MSNJ appreciates the time and effort expended by the five members who hosted site visits.

Breaking News! Assembly Health Committee Schedules Tort Reform Vote

The Assembly Health and Senior Services Committee has scheduled a vote on comprehensive medical liability reform legislation this Monday, March 7 at 10:00 am. The committee will be voting on A-1982, which includes new requirements for expert witnesses, modifications to the statute of limitations, requirements for affidavits, and a prohibition on premium increases for claims that do not succeed or arise out of charitable or emergency care.

A favorable vote by the Committee on Monday will mark the most progress made on tort reform in over 6 years.  MSNJ members are encouraged to call or write their legislators, or come to the proceedings and show your support for this important legislation. For a complete listing of committee members, click here.