On May 8, the North Carolina Medical Society (NCMS) and the North Carolina Academy of Physician Assistants (NCAPA) submitted a rulemaking petition to the Department of Health and Human Services (DHHS) regarding mandatory Medicaid enrollment for physician assistants (PAs) and nurse practitioners (NPs) who provide care to Medicaid and North Carolina Health Insurance Program for Children (CHIP) patients. View the petition here. It is the position of both the NCMS and NCAPA that DHHS may not require enrollment of PAs and NPs until a rule is adopted pursuant to the state Administrative Procedure Act, NC General Statute 150B-1. DHHS has 30 days to respond to the petition.

In the petition, the NCMS and NCAPA offer the following reasons why the proposed rule should be adopted:

• To comply with federal regulations published by the Center for Medicare and Medicaid Services (CMS) that mandate, “the State Medicaid agency must require all ordering physicians or other professionals providing services under the state plan or under a waiver of the plan to be enrolled as participating providers.” In October 2011, DHHS requested that CMS approve the addition of PAs to the State Plan. That request is still pending, but is expected to be approved.
• DHHS cannot unilaterally require PAs, NPs or other healthcare professionals to enroll as participating providers because the rulemaking exemption available to DHHS for developing medical coverage policies does not apply “in adopting new or amending existing medical coverage policies pursuant to GS 108A-54.2”
• DHHS Division of Medical Assistance (DMA) has made multiple, conflicting announcements over the last nine months. These monthly changes have created confusion about what the DHHS/DMA expect from the provider community.
• DHHS officials have already agreed with the NCMS and NCAPA that rules are required to mandate direct enrollment. Even though DMA has made promises to have stakeholder meetings and has given verbal assurances since September that draft rules were being developed and would be available shortly, no rules have materialized and planned meetings called by DMA were cancelled. DMA continues to signal that it will proceed with requiring direct enrollment before completing the rulemaking process, despite repeated objections from both the NCMS and NCAPA.

The NCMS and NCAPA will continue to press the DHHS and DMA about abiding by existing protocol in amending the State Plan. Updates will continue to be provided in future Bulletin issues.

Stage 2 Meaningful Use Proposed Rule Comment Letter

In last week’s Bulletin, the NCMS announced that, along with other professional medical associations, the Society will be submitting a comment letter pertaining to the State 2 Meaningful Use proposed rule. The proposed rule outlines the requirements for the next stage of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program administered by CMS. Click here to view the comment letter, which was submitted May 7.

Medicare Conditions of Participation (CoPs) Revised Proposed Rule

In October 2011, CMS published a proposed rule to revise the Medicare Conditions of Participation (CoPs) for hospitals that the American Medical Association (AMA), along with several state and national specialty societies, including the NCMS, submitted formal comments to CMS that voiced strong opposition to several of the proposals in the rule. On May 10, 2012, CMS published the final rule on CoPs and included the following improvements:

• The proposed concept of a single medical staff for a multi-hospital has been removed
• The proposed concept of the privileging of physicians without appointment to the medical staff has been removed
• A hospital’s governing body must now include at least one medical staff member
• The proposed concept of credentialing for medical staff membership in accordance with “hospital policies and procedures” has been removed
• The mandatory inclusion of non-physician practitioners on medical staffs strongly proposed by several other groups was not adopted.

CMS Releases Proposed Rule regarding Medicaid Payments for Primary Care Services

According to a proposed rule recently released by CMS, the number of specialties receiving Medicaid payment under Medicare Rates for primary care services will expand to include subspecialties. Family medicine, general internal medicine and pediatric medicine specialties were originally identified in the Patient Protection and Affordable Care Act (PPACA) to receive Medicare Rates in both the 2013 and 2014 calendar year. View the proposed rule here. The subspecialties included in the expanded list are recognized in accordance with the American Board of Medical Specialties.

In its May 2012 Bulletin, the Division of Medical Assistance (DMA) has again announced that it will require direct enrollment of all physician assistants (PAs) and nurse practitioners (NPs) who treat Medicaid patients. This time the enrollment deadline is June 30; these practitioners must bill under their own number as of July 1. Since additional details about this initiative have always been and remain suspiciously absent, the NCMS along with the North Carolina Academy of Physician Assistants (NCAPA), continue to urge medical practices to hold their enrollment applications.

Since last September, DMA has been looking to require direct enrollment of PAs and NPs, citing a new federal requirement aimed at improving program integrity in each state’s Medicaid program. It is true that DMA must eventually enroll these practitioners, but the NCMS position is that DMA can only do so after completing the agency rulemaking process that is required before an executive agency can adopt and enforce a new requirement upon you. Rulemaking is designed to compel DMA to describe how this requirement will affect PAs, NPs, and the medical practices that employ them. However, DMA has made it clear that it plans to shortcut this process and continue governing practices via monthly bulletin.

DMA’s handling of this issue has been opaque: cancelled meetings, unreturned phone calls and emails from stakeholders, and a lack of detail about how they will treat these practitioners once enrolled in Medicaid. For example, DMA only recently offered a PA enrollment form even though the original enrollment deadline was October. Moreover, the announcement goes beyond a simple enrollment requirement to say that “incident to” billing by PAs and NPs is no longer allowed.

We understand it is difficult for medical practices to stand idle in the face of DMA’s representations. Whether to proceed with the enrollment process is ultimately a decision for your practice to make.

Just know that at the NCMS we believe they lack the authority to require this, that the NCMS continues to press them on it, and that we believe standing by continues to be the safest option. We have notified the Attorney General’s Office and have requested a retraction of the bulletin articles and deadlines. We are also planning additional action against the agency to ensure that they comply with state law.

Related NCMS Bulletin articles:

Update on Medicaid’s Move to Require Direct Enrollment of PAs (03-02-12)

Physician Assistant Medicaid Enrollment Update (11-04-11)

Physician Assistants, Hold Your Medicaid Enrollment Applications! (10-07-11)

During the 2011 session, the NCMS reported to you on another round of mental health reforms outlined in HB 916. The bill sought to transition Local Management Entities (LMEs) into Managed Care Organizations (MCOs) over the course of one year. The concept was based on a pilot project that has been underway for nearly seven years at Piedmont Behavioral Health (PBH). While PBH has been working under a capitated system of care delivery for some time, other LMEs have had trouble making the transition from managing provider contracts to adjudicating and paying claims in a very short window of time. So far, just three LMEs have made the transition. Two more are scheduled to come online by the end of July with the remaining six not scheduled to go live until closer to January 2013.

Physicians and other mental health care providers have faced a myriad of problems in the areas that have made the transition. For those that have not transitioned, questions abound about the process and what to expect. A few of the problems that we have heard from NCMS members include:

• Blanket denials of service/non-payment for services previously reimbursed.
• Cumbersome re-credentialing requirements with 11 different LME/MCOs versus the previous single process with Medicaid.
• Over-flowing emergency departments because of a lack of local outpatient services.
• Back logs of patients at state mental health facilities.

NCMS is working with a coalition of partners to ensure that this transition has more predictability, more standardization across the different LME/MCOs, and less interruption of services to patients. We are working with legislators to identify additional oversight and assistance that can be provided to the LME/MCOs in order to support this policy change that the North Carolina General Assembly has determined will go forward.

It is important that we continue to hear from you through this transition to ensure that we are being proactive, not only at the North Carolina General Assembly, but also at the DMA. Please continue to reach out to our Government Affairs team with your concerns so that we can ensure that you are not only compensated for the vital work that you provide but that your services continue to be available to this fragile patient population. Please contact Amy Whited, Director of Health Policy at awhited@ncmedsoc.org or Conor Brockett, Associate General Counsel at cbrockett@ncmedsoc.org for assistance.

This week, the Physicians Advocacy Institute (PAI), Inc., an affiliate of the NCMS, sent a letter on behalf of more than 100 professional medical associations to the Centers for Medicare and Medicaid Services (CMS) Acting Administrator Marilyn Travenner reporting their concerns about the “Returning and Reporting of Overpayments” proposed rule made effective in February 2012. Read the letter here. 

In the letter, PAI highlights several aspects of the rule that CMS should clarify, including:

• Physicians should not be obligated to proactively search for an overpayment unless there is reason to believe a specific overpayment exists;
• CMS should finalize a policy that the 60-day reporting period begins on the day that an error-specific overpayment inquiry has ended as to not cause confusion with numerous reporting days;
• PAI strongly opposes the proposed 10-year look back period and to remain consistent, CMS should implement a three-year look back period;
• CMS should limit the reach of the overpayment obligation to no earlier than the passage of the Patient Protection and Affordable Care Act (ACA) on March 23, 2010;
• If a physician has received an overpayment determination from a CMS auditor, the processes and appeals rights of that overpayment audit program should be controlled to avoid confusion and duplication of payment, and physicians should be exempt from obligations under the ACA related to that overpayment;
• Physicians should be able to administratively appeal an overpayment determination;
• CMS should omit the proposed reporting requirements pertaining to overpayment reports since the reason behind overpayment reporting is currently not a requirement;
• To avoid confusion, the proposed standard reporting form should be released with CMS’ final rule on this matter. The form should also include a section for physicians to note their disagreement with the audit findings; and
• CMS should reconsider the estimated cost of implementing the proposed rule.

The NCMS will continue to monitor this issue closely. Refer to upcoming Bulletin articles for updates.

The American Medical Association (AMA) recently recognized the NCMS for its involvement in requesting the Centers for Medicare and Medicaid Services (CMS) delay obscure place-of-service coding requirements, set to take effect April 1, in an email alert sent to AMA members. The efforts of the AMA, the NCMS and other state and specialty medical societies, convinced CMS to delay the coding implementation until October 2012. Click here to view the email alert, which should be available shortly.

 Related NCMS Bulletin article:

NCMS Persuades CMS to Delay Obscure Place-of-Service Coding Requirements (3-30-12)

Over the past couple of months, the NCMS has been publishing weekly frequently-asked-questions (FAQ) in the Bulletin due to the high volume of inquiries coming in through the NCMS Member Resource Center. Now we’d like to know what types of questions and answers NCMS members would like to see each week. Take this two question survey to let us know your thoughts. Your participation will help the Resource Center meet member needs more effectively.

This week the Office of Inspector General of the U.S. Department of Health and Human Services (DHHS) released a report entitled “Early Assessment of Audit of Medicaid Integrity Contractors,” which found that 81% of the Centers for Medicare & Medicaid Services’ (CMS) pre-screened audits undertaken to fight waste, fraud and abuse in Medicaid were either unable or unlikely to identify overpayments during a recent six-month period.
 
The analysis found only 11% of assigned audits conducted from January 1 – June 30, 2010 by Medicaid Integrity Contractors (MIC) were completed with $6.9 million in overpayments identified, $6.2 million of which resulted from seven completed collaborative audits involving Audit MICs, Review MICs, States, and CMS. The remaining audits had not progressed enough to draw conclusions about likely outcomes.

Failure to find overpayments was blamed on the use of audit algorithms previously found ineffective, errors in the data, and the contractors who selected the providers to receive audits based on their likelihood to receive overpayments. The CMS spent $17.2 million on all such contractors in fiscal 2010. The report recommended the CMS increase its coordination with each state’s Medicaid officials.

The NCMS provides assistance and education to medical practices on how to prevent such audits.  Visit the NCMS Health Care Audit Resource Center for more information. PractEssentials, a NCMS Foundation initiative, provides consulting services designed to help your practice identify potential problems areas, evaluate options, and implement solutions. On April 25, PractEssentials will conduct a one-hour webinar on recovery audits. For assistance from PractEssentials or for more information, contact Franklin Walker, Director of Programs, at (800) 722-1350 ext 141.

Are you a Resident, Fellow or a Residency Program Director? The NCMS offers dues-exempt enrollment for residents and fellows who enroll as part of an accredited residency training program. As the state’s leading physician organization, we are dedicated to empowering physicians to achieve their personal and professional goals.  Under this group program, complimentary membership is provided to program participants. To enroll, Resident-Fellow physicians or your group administrator should complete and return the enrollment form to ncms@ncmedsoc.org. For more information, call the NCMS Member Services Department at (800) 722-1350.

Healthcare reform, insurance mandate debated at NC health forum, 3-20-12, MedCity News
Writer Frank Vinluan provides an update to the NC SPIN forum that took place earlier this week and discussed the Affordable Care Act.

Med schools shift focus to team-based care, 3-19-12, amednews
Staff writer Carolyne Krupa reports that medical schools are adapting to a change in the healthcare system by giving students experience working with other future health professionals.

Health insurer sponsors obesity challenge, 3-21-12, The Herald Sun
Reporter Laura Oleniacz informs that Blue Cross and Blue Shield of North Carolina will be holding a competition that will award entrepreneurs $20,000 for the best ideas to reduce obesity.

Mobile hospital tested; ready to assemble in a disaster, 3-21-12, Times-News
Staff Writer John Harbin reports on the progress of the National Mobile Disaster Hospital located at the Western North Carolina (WNC) Agriculture Center.

Doctors find clue in quest to predict heart attack, 3-21-12, The News and Observer/Associated Press
Reporter Lauren Neergaard reports on new findings that by searching blood for cells that appear to flake off the lining of a diseased artery may help predict heart attacks.

FDA panel: Dissolvable tobacco could reduce risks, 3-22-12, The News and Observer/Associated Press
Reporter Michael Felberbaum writes that a FDA panel says dissolvable tobacco products could reduce health risks but potentially increase number of tobacco users.

In the March Medicaid Bulletin issued this week, DMA again announced that physician assistants are eligible to enroll directly as Medicaid providers.  The article confusingly states that PAs “may be enrolled effective April 1.”  It is not clear if April is the new deadline that DMA has set for the submission of enrollment applications.

For months now, the North Carolina Medical Society, with the support of the NC Academy of Physicians Assistants and the NC Medical Group Mangers, has advised PAs and their practices to hold their Medicaid applications.  (See NCMS’s previous articles on this topic from October and November.)  

Because DMA has done little to clarify its authority to require enrollment, our position remains the same.  Of course, this is ultimately a decision best left to the practice, but in our view, the safest course of action for PAs and practices is to continue to hold their application.

We call on DMA to bring forward its timeline for completing the administrative rulemaking process, clear application instructions for PAs and practices, the expected compensation rate for these professionals, billing guidelines, and future opportunities for stakeholder input.

A few months ago, the North Carolina Medical Society, NCHA, and the NC Radiology Society jointly petitioned the NC Department of Insurance regarding BCBSNC’s move to implement a new radiology reimbursement policy in a way that we believed violated state law. The DOI agreed and instructed BCBSNC that, in order to implement the policy, the insurer must first follow a formal process for amending its contracts with affected physicians and facilities. Review that story here.

Since then, BCBSNC has appealed the DOI’s decision to an administrative hearing officer.  Quickly after BCBSNC filed its appeal, the NCMS, NCHA, and NCRS requested to intervene in the case and were granted full-party status by the Hearing Officer.  As full parties, the three organizations will help the DOI defend its position that BCBSNC must follow the fair contracting statutes before implementing the radiology policy.  The appeal is still pending.

In an interesting twist, BCBSNC Network Management simultaneously issued proposed contract amendments to radiology providers in the network, seemingly in compliance with the DOI’s initial decision and relevant state laws. This was also what the NCMS, NCHA, and NCRS had been asking – and then pushing – BCBSNC to do all along.

In its written notice to affected practices, BCBSNC disclosed that it would implement the radiology policy in April 2012. Physician practices and facilities in receipt of this notice should know that, at this point, the outcome of BCBSNC’s appeal at DOI will likely have no effect on the proposed contract amendment that you may now be considering.

BCBSNC has indicated to us that its contracting effort does not change their intention to pursue an appeal of DOI’s decision. This is unusual, though, since the original decision instructed BCBSNC to comply with the statutes before moving forward, and it now seems like they have.  This paradox was the basis for a Motion to Dismiss the Appeal that was filed by DOI this week and will be supported by the three provider organizations.

Check back for additional updates on this issue from NCMS.

Former university doctor running for NC governor, 2-28-12, WRAL.com/ The Associated Press

WRAL reported that NCMS Member Bruce Blackmon, MD, will be running for North Carolina governor in 2012.

Most Americans like Medicare just the way it is: survey 3-1-12, Modern Healthcare

Writer Jessica Zigmond provides findings from a Kaiser Family Foundation survey that states Americans favor the Medicare program as is.

$375M Health Care Scheme Went Unnoticed for Years, 2-29-12, ABC News/ Associated Press

Reporter Nomaan Merchant reports on how several Texas health care providers are being investigated for fraudulent Medicare and Medicaid claims that went unnoticed for half a decade.

NC Pediatricians Offer Medical Help – and Literacy, 2-29-12, Public News Service

Writer Stephanie Carroll Carson reports on the national “Reach Out and Read” program, which Surf Pediatrics in Nags Head, NC is actively participating in.

States with high cost, growth in ER dental visits, 2-28-12, The News and Observer/Associated Press

Findings show that dental visits to North Carolina emergency rooms totaled more than 69,000 in 2009, which is the 10^th most common reason for ER treatment in the state.

Smartphones take role in monitoring health, 2-27-12, The News and Observer/ The New York Times

New York Times Writer Peter Wayner reports on how smartphones are the future of medicine.

New rounds for med students, 2-25-12, Modern Healthcare

Writer Andis Robeznieks finds that new doctors in 2020 will not only focus on resident work hours but have good bedside manner with caregivers,  due to new accreditation system for residency programs and a new medical school entrance exam.

Family may use secret recording in medical negligence suit, 2-27-12, amednews

Writer Alicia Gallegos reports on the growing liability risks doctors face as handheld recording devices become more common.

Physician rating website reveals formula for good reviews, 2-27-12, amednews

Reporter Pamela Lewis Dolan writes about an online physician rating site, DrScore.com, which found that happy patients mean short waiting room time and longer time in exam room.

Palmetto GBA has issued letters to many physician practices as part of a Service-Specific Probe that every Medicare Administrative Contractor is required to conduct. The letters, sent from the Medical Review (MR) Department, explain that Palmetto has identified the physician as an outlier for a specific procedure and will be performing a prospective audit on a limited number – typically around 40 – of your claims.  This does not automatically mean you have done anything wrong or that you will have to pay money back.  The purpose of the review is to validate claims that were submitted, and if necessary, prevent inappropriate Medicare payments.

Note that Palmetto GBA’s first letter does not request any records. 

The Service-Specific Review Process

Palmetto’s system will randomly select for review claims containing the CPT code of the targeted service. (Additional services billed on the same claim that are not being monitored will continue to be processed.) Palmetto will then issue Additional Documentation Request (ADR) Letters to the practice, asking for medical information to substantiate each selected claim.  Records should be submitted within 30 days of receiving the ADR Letter.

The MR Department will use the reviewed claims and medical records to calculate a charge denial rate (CDR), which determines the percentage of charges, if any, that have been billed in error. If they find an issue with your submitted claims, you may receive a Letter of Finds, which will ask you to participate in a corrective action plan. Once that plan in submitted, a second analysis will be completed at a later date.

Where to Go for Help

For additional information from Palmetto GBA, please refer to their Medical Review Progressive Corrective Action (PCA) Process website.

You should also review the new NCMS/PAI white paper, Medical Audits: What Physicians Need to Know, located on the NCMS Fraud & Abuse webpage.  (Scroll to page 12 of the document for information on Service-Specific Probes.)

Finally, additional questions and developments can be directed to Kristin Freeman in the NCMS Member Resource Center at 919-833-3836 or kfreeman@ncmedsoc.org.

NCMS will continue monitoring this audit and will provide updates as we receive them.

Proposed Stage 2 requirements for eligible professionals and hospitals to qualify to participate in the Medicare and Medicaid electronic health record incentive program were released last evening by the Centers for Medicare and Medicaid Services (CMS). They will be published in the Federal Register on March 7, 2012.

Citing CMS officials, Modern Healthcare reports the proposed Stage 2 meaningful use requirements will “raise the bar” for eligible professionals and hospitals on the use of EHRs, electronic prescribing (eRx), and capturing specified patient-health measures. Under the proposed standards, physicians and hospitals would be required to use computerized physician order entry (CPOE) for more than 60 percent of medication, laboratory and radiology orders, which is double what is required under Stage 1 standards.

As more information becomes available, NCMS will be providing updates in the Bulletin and on the NCMS Health Information Technology (HIT) Resource Center.