November 11, 2019

Volume 14                                               Number 10 

Events 

Tuesday, November 12, 2019: Satirical hospital story! Dr. Sam Shem writes a second novel – come to an interview with him

You’re invited to a book signing and interview with Dr. Sam Shem, author of “House of God,”

as he debuts his sequel, “Man’s 4th Best Hospital,” in NYU Langone’s Schwartz E Conference Room.

3:30–4:00pm: Book Signing

4:00–5:00pm: Reading and interview with Dr. Kate Otto Chebly

5:00–6:00pm: Reception (and continued signing)

           The House of God is a satirical novel published in 1978. It follows a group of medical interns at a fictionalized version of Beth Israel Hospital over the course of a year in the early 1970s, focusing on the psychological harm and dehumanization caused by their residency training.

           RSVP and more information: John Thilletd at 212-263-5498 or This email address is being protected from spambots. You need JavaScript enabled to view it.

Wednesday, November 13, 2019, at 1:00 p.m.:  Webinar, “The Appropriate Tapering of Opioids and the Role of MAT”

The CDC’s opioid prescribing guidelines do not endorse mandated or abrupt discontinuation of opioid prescriptions. They recommend tapering only when opioid therapy’s harm to the patient outweighs its benefits; nonetheless, there are reports that some patients have been abruptly dropped from their longstanding prescriptions without appropriate tapering or referral for MAT (medication-assisted treatment).  You are invited to take part in a webinar hosted by CMS and the NYHPA (New York Health Plan Association), on the importance of appropriate tapering of opioids and the role played by MAT.  We'll discuss payors’ efforts to support appropriate tapering and MAT, and how patients can be more effectively linked to treatment services when necessary.

Speakers will include representatives from the CMS Regional Office, Wellcare, and Shatterproof, a nonprofit organization that focuses on ending addiction’s devastating effects on families.  Participants will have ample time to raise concerns and questions during this important conversation.  Register here.  Dial-in and login information will be sent in advance of the call. 

Tuesday, November 19, 2019, 5:30 to 7:45 p.m.:  Lecture, “Can Democratic Deliberation Help Us to Resolve Difficult Issues? The Case of Physician Aid-in-Dying”

This 2019 William C. Stubing Memorial Lecture, co-sponsored by the NYU College of Global Public Health and its Center for Bioethics together with the Greenwall Foundation, will be held in the Greenberg Lounge, Vanderbilt Hall, NYU School of Law, 40 Washington Square South, New York, NY 10012.   Speaker:  Dr. Amy Gutmann, President of the University of Pennsylvania and Chair of the Presidential Commission for the Study of Bioethical Issues.  Moderator:  Susan Dentzer, Senior Policy Fellow at the Duke-Margolis Center for Health Policy and former On-Air Health Correspondent for PBS NewsHour. 

Reception at 5:30, lecture at 6:30 p.m.  Seats are limited, so please be sure to RSVP.  Go to https://publichealth.nyu.edu/events-news/events/2019/11/19/william-c-stubing-memorial-lecture-can-democratic-deliberation-help.  (If you have previously RSVPed but can no longer attend, please notify This email address is being protected from spambots. You need JavaScript enabled to view it. as soon as possible to free your seat for another attendee.

Wednesday, November 20, at 7:30 a.m.: “When Is the Flu Not the Flu?” CME Webinar from MSSNY

Be sure to sign up for “When is the Flu not the Flu?” – a MSSNY CME Webinar that’s part of MSSNY’s Medical Matters series and is a companion program to October’s “Influenza 2019-2020.”  William Valenti, MD, chair of MSSNY’s Infectious Disease Committee and a member of the Emergency Preparedness and Disaster/Terrorism Response Committee, will serve as faculty for this program. Registration is now open for this webinar here.  Please click here to view the flyer for this program.

Educational objectives:

• Recognize the distinction between types of influenza and other illnesses that present similarly
• Describe key indicators to look for when diagnosing patients presenting with flu-like symptoms

Additional information or assistance with registration may be obtained by contacting Melissa Hoffman at This email address is being protected from spambots. You need JavaScript enabled to view it..

To access the October Webinar, “Influenza 2019-2020,” go to MSSNY’s CME

CME website, https:/cme.mssny.org.  (You will need to create an account if you don’t already have one.)

The Legislative Horizon

Single Payer:  Testimony of Dr. Scot Glasberg, Chair, NYCMS Single Payer Task Force

On October 3, 2019, Dr. Scot Glasberg delivered testimony at a joint hearing of the Health Committees of the New York State Senate and Assembly, stressing that physician payments under any NYS single payer system must be assured and adequate, and medical decision must be made only by physicians.  To read the testimony, click here. 

The Surprise Bill problem in Congress isn’t going away!  Please contact legislators  

Surprise Bills are still the subject of furious debate in Congress. Because of your efforts and those of medical societies across the country, the prospect of handing over to insurers the power to set the benchmark for all fees is no longer a done deal. In fact, House Bill HR 3630, which would do just that, has only 3 cosponsors - while HR 3502, which resembles New York’s law, has 100.  However, this fight is far from over; the insurers are waging their battle on many fronts.  To communicate with members of Congress, please go to https://freeroots.com/campaign/mssny-end-surprise-billing.  

(And note:  Sending an email is great, but if you happen to have a few moments to make a phone call as well, that will be very helpful.  The Freeroots message center whose link we have provided above, includes a call function you can choose.  Phone numbers and a suggested message are supplied for you.)  

What’s happening:  Bills are being considered that could set limits on out-of-network physicians’ hospital and ER fees – using limits determined by the insurance companies.  Out-of-network physicians could be hit hard, with some dropping ER call or even closing their practices.  In-network physicians’ fees could be lowered too.  Patients’ access to care could be severely jeopardized.  

What has led up to this: “Surprise bill” situations – when, for one reason or another, the patient (a plan enrollee) had no choice but to be treated by an out-of-network doctor.  (Example:  The patient had a late-night emergency, when an out-of-network surgeon was the only one in the ER.)  The patient may get an out-of-network bill - sometimes a large one.  (Partly at fault:  The insurers themselves, for allowing networks to be narrow and thin!) 

The pressure on Congress:   Public indignation.  A patient shouldn’t be responsible for a huge unexpected bill from an out-of-network doctor he or she may not even know.  That bill should go to the insurer.   

The problem:  Some fee limits must apply.  But what limits?  Should bills be limited to what the “typical” or “average” doctor would charge?  And here’s the crucial question:  Who determines that “typical” charge?  Should it be the insurer (which may have its own statistical biases), or should it be an independent entity?  

The dangerous influences Congress is now following:  Insurers are urging the use of their own, skewed physician fee statistics.  This technique is sometimes called “benchmarking,” or the use of a “default rate.” 

The direction we urgently need Congress to go in, instead:  We need to push for legislation that uses independent statistics – as does New York State’s successful, independent-source “baseball arbitration” system.  If we don’t fight, we may even lose our own New York State system (eventually).    

A little background on fee-setting:  The insurers’ approach – versus the New York approach

How will out-of-network fees be set?  Right now, Congress may be inclined to favor S.1895, which would allow the fees to be set by insurers, using their “median” rates - even if these rates don’t cover the costs of care.  But we are recommending the Ruiz/Roe legislation (HR 3502), which would allow something similar to the NYS “baseball arbitration”-style IDR system (in which FAIR Health’s independent out-of-network data plays an important role).  Following is a quick thumbnail on the consequences if insurers set fees.  In- and out-of-network reimbursements will be lowered, and access to care could be jeopardized.    

Consequences:  With out-of-network rates limited:

-           Fewer specialists may be available in ERs; patients may suffer. 

-           Out-of-network physicians, in general, will feel the direct impact of the lower rates.  Some practices may close.  Patients may have fewer choices of practice sites and styles. 

 Insurers will also feel less pressure to keep in-network rates and network sizes adequate:

-           If out-of-network rates are lower (hence cheaper for insurers), insurers will have less incentive to insist on “all in-network” care.

-           We could see an inexorable downward “median creep”:  

            o          If a “median” rate is favored, why should insurers go on paying physicians who are currently in their networks, more than the median rate?

            o          Insurers may decline to renew contracts of physicians currently in their networks, who are currently paid more than the median rate.

            o          Thus, there may be fewer physicians on the “above the median” part of the curve and the whole curve may shift down.   

-           Meanwhile, since the out-of-network environment won’t be welcoming either, physicians trying to negotiate in-network rates may have few negotiating options.  Insurers may feel even less pressure to make in-network rates attractive to physicians. 

The New York system has worked well

NY Department of Financial Services released a report detailing the great success of New York’s 2014 surprise bill law.  Between 2015 and 2018, consumers saved over $400 million and reduced out-of-network billing by 34%, in part through a reduction in costs associated with emergency services and an increased incentive for network participation.  A total of 2,595 IDR (Independent Dispute Resolution process) decisions were reached.  Decisions re hospital-visit-related “surprise” bills:  815 IDR decisions were rendered, with health plans prevailing in 13% of the cases, physicians prevailing in 48% of the cases, and split decisions reached in 39% of the cases.   Decisions re emergency-related “surprise” bills:  43% of decisions were in favor of the health plan, 24% were in favor of the provider, and 33% were split between the health plan and provider.

MSSNY and physician groups across the country are working diligently to refute the insurance lobby’s lies and half-truths, but more physician advocacy is urgently needed. MSSNY leadership and physician advocates have been meeting with key members of Congress to advocate for legislation that emulates New York’s successful model - such as H.R.3502, sponsored by Representatives Ruiz and Roe. At the same time, grave concerns have been raised about the alternative bills being pushed by insurance companies (H.R.3630, sponsored by Representative Pallone, and S.1895-Alexander/Murray), that would limit payment to out-of-network providers in these surprise bill situations to an insurer-controlled “median contracting rate.” 

When California enacted a similar law a few years ago, there was a 48% increase in complaints about patients’ loss of access to care - including problems accessing facilities, inadequate selection of providers, and delays in obtaining care or securing physician appointments.  United, Empire, Aetna and many of the other market-dominant companies already hold enormous power over physicians and their patients; they can virtually dictate the terms of care delivery.  Do not give them any more power.

Medicare Issues 

CMS Releases 2020 Medicare Physician Payment Final Rule!

On November 1, 2019, the Centers for Medicare and Medicaid Services (CMS) issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS), effective on or after January 1, 2020. Some key provisions include: 

Changes coming in 2020:  

• CY (calendar year) 2020 Physician Fee Schedule Conversion Factor: The finalized CY 2020 PFS conversion factor is $36.09 - a slight increase of $0.05 above the CY 2019 PFS conversion factor, which was $36.04. 

• Medicare Telehealth Services: For CY 2020, CMS is adding HCPCS codes G2086, G2087 and G2088 to the list of telehealth services.  These codes describe a bundled episode of care for the treatment of opioid-use disorders. 

• Review and Verification of Medical Record Documentation: In 2020, CMS is finalizing modifications to the documentation policy so that physicians, physician assistants, and advanced practice registered nurses (APRNs – nurse practitioners, clinical nurse specialists, certified nurse-midwives and certified registered nurse anesthetists) will be permitted to review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, medical, physician assistant, and APRN students, nurses, or other members of the medical team. 

• Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs): For more information on this aspect of the 2020 Fee Schedule changes, go to the link below or contact NYCMS through the Third-Party Insurance Help Program.  Call Susan Tucker, 212-684-4681, or email This email address is being protected from spambots. You need JavaScript enabled to view it.. 

-        https://www.cms.gov/Center/Provider-Type/Opioid-Treatment-Program-Center.html 

Office/Outpatient Evaluation and Management (E/M) Services:  Changes coming in 2021: 

In 2021, CMS will be aligning Evaluation and Management (E/M) coding with changes that have been adopted by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel as follows.

• The five levels of coding will be retained for established patients; but for new patients, the number of levels will be reduced to four (code 99201 will be deleted).  Also, code definitions will be totally revised and the fees will be increased. Please note, CMS will not apply these 2021 fee increases to E/M post-operative visits in the global surgical payment package; the agency is continuing to evaluate the data concerning this issue. 

• For all the codes, CMS will revise how the clinician represents physician time and the medical decision-making process.  The performance of history and exam will only be required if they are medically appropriate.  And, the clinician will be permitted to choose the E/M visit level based on either medical decision-making or time. 

• For prolonged service time, CMS will increase payment for office/outpatient E/M visits and add a new CPT code. 

• CMS is also strengthening the Medicare-specific payments for primary care and non-procedural specialty care that were finalized in the CY 2019 PFS final rule.  The clinician will be able to use a single add-on code describing the work associated with visits that are part of ongoing, comprehensive primary care, and/or are part of ongoing care related to a patient’s single, serious, or complex chronic condition. 

Quality Payment Program/MIPS: 

Physicians will now need to attain 45 points in order to avoid a 9% penalty in 2022, up from the 30 points they needed to attain in 2019 in order to avoid the 7% penalty in 2021. 

Information on how to meet this requirement in order to avoid the penalty will be forthcoming. To learn more, click on the link here or contact NYCMS through the Third-Party Insurance Help Program.  Call Susan Tucker at 212-684-4681 or email This email address is being protected from spambots. You need JavaScript enabled to view it..  

Quality Payment Program Fact Sheet - https://qpp-cm-prod-content.s3.amazonaws.com/uploads/737/2020%20QPP%20Final%20Rule%20Fact%20Sheet.pdf

The HICN to MBI transition period ends 12/31/19 – After that, all claims must be submitted with MBIs only

Beneficiaries who not yet received their new Medicare cards must contact 1-800-Medicare to update their home addresses, to ensure that another card can be mailed to the correct address.  

As you are aware, the Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) for all Medicare Beneficiaries. All new Medicare cards have been issued, and CMS is reminding Medicare patients to bring the new card with them to all of their physician and provider medical/hospital visits.  The transition period will end on 12/31/2019, and all claims and transactions MUST use the MBI as of January 1, 2020.  Providers must begin to use the MBI as soon as possible; CMS does not want them to have any issues once the transition period ends.

 Here are a few ways to get the new MBI: 

Ask your Medicare patients during Patient Intake/Registration:  At time of service, ask your patients for their new Medicare card.  

-        For those patients that are not able to give their card during their visit, please offer them this flyer created by CMS as a reminder to bring you the card the next time they visit, or send it to you in an alternate way.  The flyer is at this link: Get Your New Medicare Card. 

-        If they don’t have their card with them at the time of service, remind them that they can use MyMedicare.gov to get their new Medicare number. 

-        Offer patients who do not have their card the following CMS-approved flyer: Get Your New Medicare Card. 

You can also use the NGSConnex secure MBI look-up tool:  Registered users of NGSConnex can access the MBI Lookup Tool to get their patients’ MBIs. The user must enter the patient’s first and last name, date of birth, and Social Security number (not the old Medicare number, or HICN), and the provider’s NPI. 

If you don’t have access to NGSConnex:  Go to NGSConnex to register for a free account. 

Another approach:  Check the remittance advice (formerly the Explanation of Medicare Benefits).  Throughout the transition period, when a claim is submitted with a valid HICN, the MBI will be shown on the remittance.  (Note:  The MBI on the remittance is not a verification of Medicare entitlement. Please make sure that you go through normal eligibility verification steps once you have the MBI.)