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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.


Medical Audits: What Physicians Need to Know

Government and private payers have increasing pressure to lower healthcare costs. This inevitably drives them to audit practices for alleged overpayments and to attempt to recoup. It is imperative that physicians understand the risk of these audits, how to prepare and how to respond. Physicians need to prepare for and manage external payer audits just as they manage any other part of the business side of their practices to minimize the risk of being audited and to ensure that any audit findings are fair and accurate.  Read a comprehensive white paper prepared by the Physicians Advocacy Institute (PAI) and share it with your staff.

PAI is a non-profit advocacy organization established in 2006 with funds from the class action settlement agreements against major national for-profit health insurers. MSNJ was a signatory on each of the national class-action lawsuits and actively engaged in enforcing compliance. Larry Downs, MSNJ’s CEO and General Counsel, is a member of PAI’s compliance committee.

PAI’s mission is twofold: to guarantee compliance with the national class-action settlement agreements and to work with the settling health insurers to encourage voluntary compliance with the settlements after their expiration; and, to develop projects and tools that guarantee the viability of physicians’ medical practices and the ability of physicians to deliver quality patient care.

PAI’s new audit tool will:

  • assist practices in determining their risk of being audited
  • describe the various type of audits
  • discuss the audit process
  • discuss how to respond to an audit
  • provide tips to analyze audit findings; and
  • provide guidance on how to appeal any adverse audit determinations.

Significantly, the tool provides information on extrapolation and the manner in which to test the validity of an extrapolation methodology. Frank Cohen, MPA, MBB, of The Frank Cohen Group, LLC, is an author of the white paper. Frank Cohen previously made a presentation to MSNJ on audits in a webinar format. Review the slides from his presentation.

Hospitals Immune from Civil Liability under Professional Reporting Act

A New Jersey appellate division court has found a hospital immune from civil liability under the New Jersey Healthcare Professional Responsibility & Reporting Enhancement Act, N.J.S.A. 26:2H-12.2a, et seq. in Senisch v. Carlino. The “Cullen Act” was passed in response to the murder of terminally ill patients by Charles Cullen, a registered nurse, in healthcare facilities in Pennsylvania and New Jersey.

The act requires healthcare facilities to truthfully provide information about a former employee’s job performance as it relates to patient care and the reason for separation. At issue was whether the hospital had provided negative information about a former employee’s job performance as it related to patient care in good faith, without malice, to another inquiring healthcare facility in order to be entitled to immunity under the act. The case involved a formerly employed physician assistant.

The Professional Responsibility & Reporting Enhancement Act applies to physicians. Physicians should be aware of and address any negative information that may be contained in the files of healthcare facilities in which they work.