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2014 Medicare Physician Fee Schedule Issues

It was recently brought to our attention that Novitas has yet to post the correct 2014 conversion factor for anesthesia. We also have concerns that the ambulatory surgery center and vaccine fee schedules are not up to date. MSNJ asked Novitas about the timeline for posting the corrected fee schedules. We were advised that they are in the process of updating the anesthesia conversion factor on the website. We are still awaiting information on the ASC and vaccine fee schedules.

Novitas also advised MSNJ that it has loaded the regular 2014 fee schedule and is prepared to accept 2014 claims. Novitas is still working on posting the 2014 physician fee schedule in the file formats that may be imported into billing software. For now, Novitas is posting the files in a basic text only format to give practices an opportunity to review the 2014 fees. Likewise, these fees are not yet available in Novitas’ interactive fee calculator.

We believe that if you bill Medicare less than the 2014 fee schedule amount, Medicare will pay the lesser amount based on past experience. Likewise, in the past, Medicare would not reconsider claims that were paid at a billed amount that is less than the current Medicare fee schedule. We have requested clarification on this issue from Novitas since it appears from the web site that these fees are up to date and physicians may have charged less than what they are entitled to through no fault of their own. To avoid this issue, physicians may want to consider billing Medicare at the practice’s regular fee schedule to ensure that the amount billed is above the Medicare fee schedule amount. Another option is to hold claims until the correct information is posted on the Novitas website.

Please stay tuned to e-News for more information as it becomes available.

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Medicaid Expansion Update—Enrollment Glitches

In November, the NJ Medicaid program advised that for individuals applying through the federal Marketplace there would be a lag time between federal and New Jersey approval. It further advised that it was able to handle the lag and that New Jersey had the second highest number of Medicaid enrollments of states using the federal Marketplace.

On December 20th, a story broke indicating that State officials said that those who applied for health coverage using the federal government’s website are actually unable to be enrolled because the State cannot process the eligibility information from the federal web site.  Per the article, “New Jersey Medicaid said in­formation it received from the federal insurance marketplace for about 25,000 residents who qualify for free health coverage from New Jersey’s program for the poor is ‘unusable.’  Their applications can’t be processed, and they can’t yet be enrolled for coverage that is supposed to begin on January 1.” See more.

But, MSNJ was recently informed that though,

“the flat file sent to NJ Medicaid by the federal Marketplace still is unusable…individuals who applied to the Marketplace between October 1 and December 31, who are verified as Medicaid eligible, will have their coverage backdated to January 1.

MSNJ immediately asked the Division for guidance and was given the following advice:

-This problem actually affects about 60,000 patients.

-Patients in this category will have letters from CMS stating that they are considered eligible by CMS. This letter only confirms eligibility; it does not place the patient in a plan or provide an ID number. Please be advised that CMS is telling patients that physicians will be able to confirm enrollment, but that is not the case.  The following advice that CMS is giving to patients is not accurate for enrollees in New Jersey:

“If you received a letter telling you that you have been enrolled in Medicaid or CHIP, but you haven’t received an enrollment card from your state agency or from one of its health plans, you should still be able to get health care services. If you need care, show your provider a copy of your eligibility letter. Your provider can verify your enrollment when you go for care.”

– As such, these patients will be treated much like presumptively eligible patients are already treated in New Jersey: they will be considered traditional Fee for Service (FFS) until the State has been able to confirm their eligibility and enroll them in a plan.

-True Medicaid HMO plan enrollment cannot be done until February 1st, which is the next enrollment period for Medicaid plans.

-While other states are asking patients to re-enroll directly with the State Medicaid program, New Jersey is not doing so.  NJ Medicaid will work to process the applications that came through the federal exchange as soon as possible.

View the CMS FAQs.

Bottom line for our members: You may wish to see a patient who presents a CMS letter, but there is no obligation to do so.  The clients will be considered traditional FFS until they select and are enrolled in an HMO, so a provider would bill Medicaid and get paid the FFS rate.  Once enrolled in a health plan, the client will have to go to a provider within that network.

MSNJ Legislative Update: December 20, 2013

All Payer Claims Databases

The Assembly Health Committee took testimony on the concept of creating an all payer claim database, partly for the purpose of determining proper charges and reimbursement for certain services, particularly out of network services.  MSNJ has testified on existing legislation, stating that APCDs can be a good tool. MSNJ opposes legislation that would create artificial limits on out of network charges and supports improvements on in network issues first. See media coverage here. 

 

Breast Density

The Assembly passed the final version of A2022/S792, which now heads to the Governor’s desk.  MSNJ worked on this bill in great detail. The bill 1) requires insurance companies to cover certain screenings, 2) requires physicians to provide information to  certain patients regarding breast density and 3) requires study of breast cancer risk factors. Radiology facilities must distribute to certain patients a notice that reads as follows: “Your mammogram may show that you have dense breast tissue 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, in some cases, dense breast tissue can make it harder to find cancer on a mammogram and may also be associated with a risk factor for breast cancer. Discuss this and other risks for breast cancer that pertain to your personal medical history with your health care provider.  A report of your results was sent to your health care provider. You may also find more information about breast density at the website of the American College of Radiology.” The bill states that it does not impose a standard of care obligation upon a patient’s health care provider.  The bill requires the Mandated Health Benefits Advisory Commission to prepare a report regarding the implementation and administration of the bill, including analyses of social, medical and financial impact. The bill requires the Department of Health, in conjunction with the Medical Society of New Jersey, to convene a work group to review and report on strategies to improve the dialogue between patients and health care professionals regarding risk factors for breast cancer and breast imaging options. 

 

Self-Referral Laws

The Senate and Assembly have both passed A4222/S2779, which allows practitioner with financial interest in health care service providing lithotripsy to refer patients to that health care service if certain conditions are met. MSNJ and New Jersey urologists support this bill, which is a “clean up” to the reforms made to self-referral laws (the Codey Act) in 2009. Lithotripsy was left out of the exemptions in 2009.  The bill heads to the Governor.

 

Gender Changes on Birth Certificates

The Senate and Assembly have both passed A4097/S2876, which allows more people to change their birth certificates.  To obtain the amended certificate, a person would be required to submit:  1) a form provided by the State registrar of vital statistics and completed by the person’s licensed health care provider which indicates that the person has undergone clinically appropriate treatment for the purpose of gender transition, based on contemporary medical standards, or that the person has an intersex condition; and 2) a certified copy of a court order indicating the person’s name change, if the person has changed his or her name.  Under current law, a person is required to undergo sex reassignment surgery to receive an amended birth certificate.

 

Emergency Generators

The Assembly has passed A4324, which requires that certain health care facilities be either equipped with a generator or be equipped with an appropriate electrical transfer switch and wiring to which a portable generator can be connected in order to provide back-up electrical power to the facility.  Health care facilities included under the provisions of the bill are the following: nursing homes; assisted living facilities; comprehensive personal care homes; pediatric community transitional homes; federally qualified health centers; dialysis centers; hospice in-patient cares; or residential health care centers connected to another licensed facility.  The bill requires that these facilities be equipped with a generator or be generator ready within three years of the effective date of the bill.  The bill also requires the New Jersey Economic Development Authority (“authority”) to offer financial assistance in the form of low-interest loans to eligible facilities for the purchase and installation of a generator, or to make the facility generator ready (the loans are to have an interest rate of not greater than two percent). There is no Senate counterpart.

 

Reconstructive Breast Surgery

The Senate has passed S374, which grants a state sales tax exemption for services prescribed by a doctor in conjunction with reconstructive breast surgery. The procedures, currently subject to the 7 percent tax rate, are utilized to restore the appearance of the breast. The bill addresses a current loophole where insurance providers cover the costs of the procedures but pass on the cost of the sales tax to the patient.  The Assembly version of the bill, A4526, is awaiting final adoption, which will likely happen in lame duck.

 

Physician Loan Redemption

The Assembly Higher Education passed A4507, which establishes a Physician Loan Redemption Program. MSNJ, along with NJ AFP and COTH worked expediently to improve the bill that was passed by the Senate in a skeletal, flawed form.  This is a lame duck priority for policy makers and will reach the Governor’s desk this month. With our input, the bill now bill provides for redemption of eligible qualifying loan expenses for physicians who work for no less than four years at an approved site in the clinical practice of primary care or in the clinical practice of specialized care if the specialty is projected to experience a significant shortage. The bill also provides that the redemption of eligible qualifying loan expenses under the program will be exempt from the program participant’s individual New Jersey State income tax.  Also, in the case of an approved site that is a private primary care physician practice that has hired a loan redemption program participant, the site will have a State income tax exemption for all practice revenues received from providing services under the Medicaid program.

 

Any Willing Provider

The Senate Health Committee took testimony on a bill that would prohibit an NJ insurance company from having exclusive contracts with providers. The bill stems from Horizon’s exclusive contract with LabCorp, but is not limited to lab services.  The Association of Health Plans opposes the bill, stating that keeping narrow networks is a business decision they should have the flexibility to make to control costs (for consumers). Please find MSNJ’s testimony here.

 

Student Eye Injuries

Both houses have passed a bill that requires the Commissioner of Education to develop an educational fact sheet that provides information about sports-related eye injuries.  Each school district and nonpublic school is to distribute the fact sheet annually to the parents or guardians of the students.  The fact sheet is to include, but not be limited to:

      —   a list of the most common sports-related eye injuries and the recognition of the symptoms of those injuries;

      — a recommendation that children seek treatment and advice from a licensed health care professional regarding the appropriate amount of time to delay the return to sports after injury     

—   a recommendation that all children participating in school sports or recreational sports wear protective eyewear;

      —   information concerning the purchase of appropriate protective eyewear; and

      —   any other information the commissioner deems appropriate.

 

Latex Gloves

The Assembly passed a bill that directs the Commissioner of Health to develop a plan to phase out the use of latex gloves in licensed health care facilities and food service establishments to address consumer latex allergies.  The Senate will likely pass the bill soon.

 

Student Health

The Assembly has passed A4415/S2367.  This bill, the “Sudden Cardiac Arrest Prevention Act”, provides student-athletes, parents, and coaches with information on sudden cardiac arrest and establishes protocol concerning removal-from-play for athletes exhibiting symptoms of sudden cardiac arrest.  The following organizations were in support of the bill: NJ Chapter of American College Emergency Physicians, American Heart Association, NJ School Boards Association and the Athletic Trainers Association of NJ.  As previously reported, the Senate passed the bill in June.

 

Mental Health Screenings

The Assembly has passed A3155, which concerns assessments of persons believed to be in need of involuntary commitment to treatment.  The bill requires that an assessment be performed prior to the performance of routine laboratory and diagnostic testing.  If, as a result of the assessment, involuntary commitment to treatment seems necessary, then the routine laboratory and diagnostic testing is to be performed.  (Laboratory and diagnostic testing is currently completed and submitted to screening services before the assessment, so this bill seeks to avoid such testing expenses if the person does not need commitment, and to reduce hospital emergency room waiting times because staff would not have to wait for test results to be reviewed before the assessment is performed.) There is no Senate counterpart.

 

Declaration of Death

Both houses have passed A3586/S2756, which removes the statutory authority of the Department of Health (DOH) and the State Board of Medical Examiners (BME) over medical standards governing declarations of death upon the basis of neurological criteria.  The bill requires that a declaration of death upon the basis of neurological criteria be made by a licensed physician professionally qualified by specialty or expertise, based upon the exercise of the physician’s best medical judgment and in accordance with currently accepted medical standards.  Joint DOH/BME regulations would no longer be needed to set forth currently accepted medical standards (including criteria, tests, and procedures) to govern declarations of death upon the basis of neurological criteria.  If they are used, the regulations concerning the declaration of death upon the basis of neurological criteria may not require the use of any specific test or procedure in the declaration of death upon the basis of such criteria.

MSNJ supports this bill.

 

Breast Milk

The Assembly has passed two bills concerning breast milk. A3702 requires the Commissioner of Health to establish a public awareness campaign to advise pregnant women, new parents, and women who are breast feeding their children about the dangers of casual milk sharing.  The campaign would, at a minimum, provide information on: risk factors associated with casual milk sharing, including disease transmission and contamination from drugs, germs, or chemicals; the federal Food and Drug Administration’s warning against mothers using donated breast milk obtained directly from individuals or other unknown sources; and human milk banks and the procedures they use to select donors and collect, process, store, dispense, or sell donated breast milk.

 

A3703 gives the Department of Health the authority to license and inspect human milk banks, including an inspection of records, files, and other data, and requires the commissioner to promulgate rules and regulations for the operation and maintenance of human milk banks.  The regulations governing human milk banks would include provisions for: staff qualifications; procedures for selecting and screening potential donors; standards for the collection, processing, storage, and distribution of donated breast milk; the maintenance and confidentiality of milk bank records; and license application, issuance, renewal, expiration, denial, suspension, and revocation.

 

Student Asthma

The Assembly Education Committee has passed A954, which creates a 16-member School Asthma Protocol Task Force.  The membership of the task force would include: the Commissioners of Education and Health and 14 public members to be appointed by the Governor as follows: four persons who are parents of children with asthma who are attending a public or nonpublic school; a licensed physician who is a pulmonary specialist; a licensed pediatrician; a certified school nurse; an advanced practice nurse certified in pediatric nursing; a school administrator; a public school teacher; a public school principal or supervisor; a local school board member; a representative of a nonpublic school; and a representative of the American Lung Association.  The task force would be responsible for selecting a school asthma protocol and developing guidelines for the most appropriate and effective means of implementing the selected school asthma protocol on a Statewide basis.  There is no Senate counterpart.

 

Medical Marijuana

The Assembly has passed A4537 which would permit State medical marijuana patients and their primary caregivers to possess, and patients to use, medical marijuana legally obtained from another jurisdiction.  The bill would also permit qualifying out-of-State medical marijuana patients and their primary caregivers to engage in any conduct related to medical marijuana permitted under New Jersey law.  In both situations, the other jurisdiction’s medical marijuana law must be recognized by the Department of Health.  The bill would additionally provide that both parents of a patient who is a minor may serve as the minor’s primary caregivers under the State medical marijuana program, and that a parent who is currently serving as a primary caregiver may concurrently serve as primary caregiver to any minor child of the parent who is a qualifying patient.  There has not yet been action on the Senate counterpart.

www.acr.org

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 www.msnj.org.

Sunshine Act Resources

The Sunshine Act, which is part of the Affordable Care Act (ACA), requires manufacturers of drugs, medical devices, and medical supplies that participate in Federal health care programs to begin reporting on financial interactions with physicians, beginning August 1st of this year. The majority of this information will be posted on a public website managed by the federal government. The key dates are as follows:

  • August 1 through December 31, 2013: Manufacturers are required to begin collecting and tracking payment, transfer, and ownership information. Thereafter, they are required to report for each full calendar year.
  • January 1, 2014: CMS expects to launch the physician portal that allows physicians to sign-up to receive notice when their individual consolidated report is available for review. This portal will also allow physicians to contact manufacturers/GPOs if they want to dispute the accuracy of a report.
  • March 31, 2014: Manufacturers/GPOs will report the data for 2013 to CMS.
  • June 2014: CMS is expected to provide physicians access to their individualized consolidated version of all manufacturers/GPO reports for the prior calendar year in June 2014. Physicians may access the consolidated reports via an online website portal maintained by CMS and will be able to seek correction or modification by contacting the manufacturer/GPO through the portal.
  • September 30, 2014: CMS will release most of the data on a public website.

View AMA’s archived broadcast from the April 25 webinar on “Physicians Preparing for the Sunshine Act: What You Need to Know and How to Prepare.” Read the Sunshine Act Physician Brochure and view FAQ’s and other resources on AMA’s website.

 

**June 30th Deadline to Avoid the 2014 eRx Penalty

CMS has re-opened the Quality Reporting Communications Support Page from March 1, 2013 to June 30, 2013, allowing physicians to request a hardship exemption for 2014. In order to avoid the 2 percent penalty in 2014, physicians must meet the requirements of the Medicare e-prescribing (eRx) program; meet one of the limited exemption categories, or obtain approval for a hardship exemption. Individual physicians who do not meet one of the exemption or hardship categories must report the eRx measure 10 times via claims between January 1, 2013 and June 30, 2013.

Groups using the group reporting option must report at least 75 times (2-24 Eligible Professionals), at least 625 times (25-99 EPs), and at least 2,500 times for groups of 100 plus. Physicians can also avoid the penalty by registering for the EHR Incentive Program by June 30, 2013, or achieving meaningful use under the EHR Incentive Program during the January 1, 2013 to June 30, 2013 reporting period. For a complete list of hardship exemptions and more information, view CMS’ Electronic Prescribing (eRx) Incentive Program: 2014 Payment Adjustment Fact Sheet.

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.