NEWS OF NEW YORK - Medical Society of the State of New York

March 4
Albany –
Be There!
MEDICAL SOCIETY OF THE STATE OF NEW YORK
NEWS OF NEW YORK
Volume 71 • Number 3 • www.mssny.org
Providing Information to Assist Physicians in the State of New York
March 2015
Governor Cuomo’s 2015-16 Health Spending Plan: $127.4M Excess Program Continues
Governor Cuomo announced his $141.6 billion spending
plan for 2015-16. Overall state spending is projected to increase
by 1.7%. He projects a budget surplus of $1.8B and proposes
to increase spending on Education by $1.1B. Spending on the
Medicaid program is projected to increase to $62M.
Items of interest to organized medicine in the proposed budget include:
• Elimination of the New York physician profile database
including the requirements for physicians to update their
profiles
• Continuation of the Excess program at $127.4M; would
establish a new provision that participation is contingent upon
a finding that physician or dentist has no outstanding state tax
liabilities
• Authorization of Retail Clinics – clinics which provide a limited list of services in retail stores- provided that they adhere
to regulations which would among other things require them:
to be accredited; accept walk ins; adhere to advertising and
signage standards; disclose ownership interests; directly
employ a medical director; and strengthen primary care
through integration of services with the patient’s other health
care providers
• Regulation of non-hospital owned Urgent Care practices
including requiring such urgent care practices to be accredited
and approved to operate by the Department of Health. Under
this proposal, the Public Health and Health Planning Council
(PHHPC) is authorized to: establish the scope of services that
Medical Audits: Top Ten Tips for Physicians to Anticipate,
Respond and Protect Their Practices
This information is provided by
Physicians Advocacy Institute (PAI) and the
American College of Emergency Physicians
(ACEP). Philip Schuh, MSSNY’s Executive
Vice President, serves on the PAI Board of
Directors.
The pressure on both governmental and
private payers to reduce the cost of healthcare and the often mistaken, but real,
public perception of rampant Medicare
and Medicaid fraud has caused both public
and private payers to increase audits of all
medical providers, including physicians. In
addition, medical audits have succeeded in
returning billions of dollars to the Medicare
and Medicaid programs and private payers.
For example, the U.S. Health and Human
Services Office of Inspector General (OIG)
has found that $7 is returned to the Treasury
for every $1 spent on audits. This is in part
because the payers have access to providers’
claims data and there are software programs
that allow payers to easily review claims
data and billing patterns to identify potential issues of inappropriate billing and fraud.
Although medical audits can be burdensome
to a physician practice and may sometimes
result in large demands for repayments, there
are things that physicians can do to mitigate
the chance of being audited and from adverse
outcomes in the event of an audit. The list
below is by no means exhaustive, but should
serve as a starting point for physicians to
consider in preparing for and protecting
themselves in the case of an audit.
Assess the Risk of an Audit
Before It Occurs
Governmental contractors and private
payers use software programs to compare
physicians with others in their specialty to
identify physicians who may be over-utilizing
2 certain CPT® codes that have been found to
be frequently improperly billed. For example a recent Supplemental Medical Review
Contractor (SMRC) audit of Medicare
claims found that 61% of the more intensive level Evaluation and Management codes
(CPT 99214 and 99215) for claims submitted between July 1, 2011 and December 20,
2012 had been improperly paid Physicians
should use one of the readily available
commercial products or information available on CMS’ website, such as the Part B
Nationalization Summary Data File (BESS),
to determine if their billing is out of line
with others in their specialty, thereby putting
them at risk of an audit. Physicians should
also review Medicare’s Comprehensive Error
Rate Testing (CERT) report to determine if
they are billing codes commonly found to
have been improperly paid by Medicare and
ensure that they are properly using and documenting these codes. Physicians who do not
conduct such an analysis are doing themselves a grave disservice. Not only are such
reviews a standard component of an effective fraud and abuse compliance program,
but they also serve to show physicians how
they are being viewed by payers. The results
(Continued on page 12)
Join the White Coat
Armada on March 4
in Albany!
Call your County Executive for
more information today!
may be provided by urgent care providers; standards for the
appropriate referral and continuity of care, staffing, equipment and maintenance and transmission of patient records
• Amendment to the OBS statute to require OBS practices to be
registered with the Department of Health and to include within
the parameters of the OBS law procedures requiring neuraxial
anesthesia and major upper or lower extremity regional nerve
blocks. Requires that OBS procedures cannot be longer than
six hours. Also requires OBS accrediting agencies to: (a)
require OBS practices to perform quality improvement and
quality assurance activities and utilize ABMS or equivalent
certification, hospital privileging or other equivalent methods
to determine competence; (b) carry out surveys or complaint/
incident investigations upon department request; and (c)
report individual findings of surveys and compliant/incident
investigations
• Authorization of the Public Health and Health Planning
Council (PHHPC) to review the type of procedures performed
(Continued on page 9)
I-STOP: Beyond the Mandate
Most of the recent dialogue surrounding
I-STOP, the Internet System for Tracking
Over-Prescribing law, has been narrowly
focused on the looming March 27, 2015
mandate that all patient medications be prescribed electronically. Last month’s News of
New York featured MSSNY’s stance on that
deadline, and we urged members to prompt
legislators and Governor Cuomo to postpone
the e-prescribing mandate by 12 months to
March 27, 2016. At press time, the Assembly
had not met to vote on the bill to delay the
mandate.
The fact remains that the mandate is coming – whether it’s March 2015 or March
2016. This month, we take a closer look at
how e-prescribing can improve practice
workflows, protect against drug misuse and,
ultimately help improve patient outcomes.
Fight Prescription Drug Abuse
Nationwide, drug overdose is the leading
cause of death from injury, according to the
Centers for Disease Control and Prevention
(CDC), with most of those drug overdose
deaths (53%) being caused by prescription
drugs. An alarming 6.2 million adults in the
U.S. use prescription drugs non-medically.
Forty-six patients die each day from an overdose of prescription painkillers, and another
6,748 end up in emergency departments for
the misuse or abuse of drugs. In 2013, a
shocking 22,767 drug overdose deaths were
related to pharmaceuticals. This is why the
CDC has termed drug abuse as an epidemic,
causing more deaths than traffic accidents.
In New York state, drug overdose deaths
have risen 56% since 1999, according to
the CDC, and New York physicians are
the first line of defense in preventing drugseeking patients from misusing prescription
medications.
How E-Prescribing Can Help
Firstly, electronic prescribing is simply more secure than paper prescriptions.
Paper prescriptions are subject to transcription errors and are targets for theft and
tampering, making it relatively easy for
drug-seeking patients to alter prescriptions
by increasing dosage, frequency or duration of medications. E-prescriptions are also
delivered directly to the pharmacy, without
exposing the physician’s DEA number to
the patient. The consequences of DEA number theft include physician identity theft,
temporary inability to prescribe controlled
substances and a damaged reputation, to
name just a few.
Workflow efficiency is another key benefit
to implementing e-prescribing. A Medical
Group Management study shows that e-prescribing helps practices achieve an average
annual savings of $15,769 per full-time physician, per year. Such savings are realized
in the form of lower administrative burdens, including reduced time for providers
and staff in clarifying and/or otherwise recommunicating with pharmacies and health
plans regarding patient prescriptions.
Another benefit to using e-prescribing for
(Continued on page 11)
Inside News
HIV Diagnosis
and Prevention
webinars
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YPS 3/21: Are you
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U.S. Supreme Court to Decide Whether Providers May Sue
Over Medicaid Rates
Question: What is the status of the lawsuit over whether
or not providers may sue in court over Medicaid rates?
Answer: On January 20, 2015, the United States Supreme
Court heard oral arguments in Armstrong v. Exceptional
Child Center, Inc. The issue to be decided is whether or
not healthcare providers have the right to bring suit in
federal court over Medicaid rates that they feel are inadequately low.
A United States District Court in Idaho ruled that
Idaho’s Medicaid rates did not comply with the requirement under federal law that states must assure payments
which “are consistent with efficiency, economy and quality of care and are sufficient to enlist enough providers”
in the program to ensure adequate access to care. The
District Court’s decision was upheld by the United States
Court of Appeals for the Ninth Circuit.
Idaho Medicaid officials petitioned the United States
Supreme Court for review. Their petition was granted
with respect to the issue of whether or not providers have
a private right of action to enforce the provision of federal law which the Idaho District Court had found the
Medicaid program had failed to meet. The legal issue con-
cerns the fact that Congress did not provide for a right to
enforce the statute in question. The providers argued that
the Supremacy Clause of the United States Constitution
gives them the right to bring an enforcement action, as
the federal law provision mandating sufficient payments
takes precedence over the Idaho state statute setting the
Medicaid rates.
The case is significant, as unless the Supreme Court
finds a private right of action for providers to institute
such suits, there is no effective enforcement mechanism
to ensure that Medicaid rates established by a state are
indeed sufficient to meet the standard established under
federal law. Absent such a private enforcement right,
the only other way to enforce this provision is for the
Department of Health and Human Services to withhold
federal matching funds from the state. We will continue
to follow this case, and report when the Supreme Court
issues its opinion.
If you have any questions, please contact our Managing
Partner, Michael J. Schoppmann, Esq at 1-800-445-0954
or via email at [email protected]
HIV 2015: Diagnosis, Treatment
And Prevention Webinars Have
Begun; Physician Registration
Now Available
The Medical Society of the State of New York is offering “HIV 2015: Diagnosis, Treatment and Prevention
– Current Perspectives.” Faculty is William Valenti,
MD, chair of MSSNY’s Infectious Disease Committee,
a member of Governor Andrew Cuomo’s “Task Force
to End the Epidemic 2020” and co-chair of the Task
Force’s clinical care committee. Educational objectives
are as follows: • Apply diagnosis and treatment for all HIV infected
individuals
• Become familiar with the key points of new HIV testing laws and understand the provisions of the HCV
law
• Implement the new HIV testing algorithm
• Describe the activities that can bring HIV to subepidemic proportions and result in individual and
community viral load suppression
The remaining webinars on this topic (content is the
same) will be held on March 10 and March 24 from
7:30-8:30 a.m. Physicians and other providers can register for the
webinar at: https://mssny.webex.com. Click on the
“Upcoming” tab and select the “Register” button to the
right of the program. Seating is limited for the webinars;
physicians are encouraged to reserve their spot as soon
as possible. The Medical Society of the State of New York designates this live activity for a maximum of 1.0 AMA/PRA
Category 1 credit™. Physicians should claim only the
credit commensurate with the extent of their participation in the activity. For assistance in registering or
questions, please contact Anna Cioffi at [email protected]
org; or at 518-465-8085. The program is supported by a
grant from the state Department of Health.
MSSNY Partners with Covisint
to Assist You with PQRS Reporting
Reporting PQRS has never been more
important. The penalty for not reporting is,
at a minimum, -2.0% but it could be more.
Understanding the rules can be confusing
but is necessary. That’s why we’ve partnered with Covisint to help. They have been
a qualified CMS registry since 2008 and have
helped thousands of eligible professionals
report PQRS successfully. They have the
expertise to help you understand how the
rules affect you and which reporting options
are available.
MSSNY members receive a discount
($195); for non-members, the cost is $299.
Eligible professionals (EP) can choose to
report on one measures group from 25 available measures groups for 20 eligible patients
with 11 of the 20 patients required to be
Medicare Part-B. EPs who can’t report using
the measures group option, or if they prefer,
can report between 3-9 individual measures
at a 50% reporting rate. EPs, who are part
of a group of 10 or more, also have additional requirements to avoid a value modifier
penalty.
Trust Covisint to provide you with all of the
details so you can make an educated decision on the best reporting option for you.
Visit Covisint at www.pqrs.covisint.com
or contact them at 866.823.3958 for more
information.
Page 2 • MSSNY’s News of New York • March 2015
40 YEARS
STRONG
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See what MLMIC can do for you.
Call (888) 996-1183 or
visit MLMIC.com/physicians
March 2015 • MSSNY’s News of New York • Page 3
PRESIDENT’S COLUMN
MEDICAL SOCIETY OF THE STATE OF NEW YORK
NEWS OF NEW YORK
Medical Society
of the State of New York
Andrew Y. Kleinman, MD President
Michael Rosenberg, MD Chairman of the Board
Philip A. Schuh, CPA
Executive Vice President
COMMUNICATIONS AND
PUBLICATIONS
L. Carlos Zapata, MD, Commissioner
News of New York
Published by Medical Society of the State of New York
Vice President, Communications and Editor
Christina Cronin Southard, Editor
[email protected]
News of New York Staff
Julie Vecchione DeSimone, Assistant Editor
[email protected]
Roseann Raia, Communications Coordinator
[email protected]
Steven Sachs, Web Administrator
[email protected]
Susan Herbst, Page Designer
News of New York
Advertising Representatives
For general advertising information contact
Christina Cronin Southard
Phone 516-488-6100 ext 355
[email protected]
The News of New York is published monthly as the official publication of
the Medical Society of the State of New York. Information on the publication
is available from the Communications Division, Medical Society of the State
of New York, 865 Merrick Avenue, P.O. Box 9007, Westbury, NY 11590.
The acceptance of a product, service or company as an advertiser or as a
membership benefit of the Medical Society of the State of New York does not
imply endorsement and/or approval of this product, service or company by
the Medical Society of the State of New York. The Member Benefits Committee urges all our physician members to exercise good judgment when
purchasing any product or service.
Although MSSNY makes efforts to avoid clerical or printing mistakes,
errors may occur. In no event shall any liability of MSSNY for clerical or
printing mistakes exceed the charges paid by the advertiser for the advertisement, or for that portion of the advertisement in error if the primary or essential message of the advertisement has not been totally altered or substantially
rendered meaningless as a result of the error. Liability of MSSNY to the
advertiser for the failure to publish or omission of all or any portion of any
advertisement shall in no event exceed the charges paid by the advertiser for
the advertisement, or for that portion of the advertisement omitted if the primary or essential message of the advertisement has not been totally altered
or substantially rendered meaningless as a result of the omission. MSSNY
shall not be liable for any special, indirect or inconsequential damages, including lost profits, whether or not foreseeable, that may occur because of
an error in any advertisement, or any omission of a part or the whole of any
advertisement.
See You In Albany March 4
Are you happy with the state of
being of a physician these days? I am sure that, like many of us,
you do not like the direction it is
going.
So, what are you going to do
about it?
If you have concerns, don’t just
complain to yourself, in the medical staff room, or on blogs. Bring
Andrew Y.
your concerns to your legislators
Kleinman, MD
and other government officials. It has often proved successful.
And one way you can productively express your concerns with the state of health care delivery is to show up
in Albany for Physician Lobby Day March 4. Let your
legislators know in person your concerns with the impact
of various policies and detrimental legislative proposals
on your patients’ ability to get the care they need.
I remember when I first decided to get involved. Several years ago, I remember a colleague angrily describing to me a problem he and other physicians had with a
particular insurance company which was inappropriately
denying coverage for their claims. It occurred to me that I, too, often found myself complaining but wasn’t doing anything about it. I realized that
we needed to stop simply talking to ourselves and instead
take action, to bring these concerns to folks who could
actually remedy these problems.
So I worked with my colleagues in Westchester County
to create a “Hassle Factor” log to generate concrete
examples of these problems that my colleagues and I
experienced, and we brought them to the attention of New
York State Attorney General’s office. This produced an
AG’s investigation into the practices of this insurance
company that resulted in a settlement that called for the
company to pay for numerous claims it had previously
denied.
And that’s just one example. Time and time again, our ability to generate significant
physician advocacy providing concrete examples about the
impact of bad health care policy on the ability our patients
to receive the care they need has produced positive results. Some physicians ask me “What has MSSNY done for
me lately”?
You Are MSSNY!
First of all, let me reiterate that MSSNY is not just
a handful of physicians and staff – It is you! It is the
embodiment of the tens of thousands of physician members across New York State. Staff can do a lot but in the
end we fail or succeed based upon our own direct advocacy to lawmakers and policymakers in support of our
goals.
And we have succeeded often. Our collective advocacy
to the State Legislature has resulted in the rejection of
countless well-intended but extremely detrimental proposals that would have raised physician medical liability
premiums, inappropriately expanded the scope of numerous non-physicians providers and imposed burdensome
government regulation of the care you provide to your
patients.
Moreover, our collective advocacy has produced numerous laws and enforcement actions that require that health
insurers pay you timely, limit the ability of insurers to
deny the care you believe your patients need, and better
assure comprehensive coverage of out of network care.
And we are optimistic that our collective advocacy
this year will produce a delay in the March 27 date for
required e-prescribing.
Many Bumps in the Road
But we face so many more challenges. There are proposals to impose heavy-handed regulation of office-based
surgery and urgent care sites, authorize corporately owned
retail clinics, and require pain management education. Not
to mention the numerous threats we again face of bills to
increase physician liability exposure and inappropriately
expand non-physician scope of practice.
And we need to make our legislators more fully aware
of the shortcomings of Exchange coverage.
I cannot say this enough – Legislative and regulatory success is the product of our collective advocacy. MSSNY staff, MSSNY physician leaders, and YOU! We
need you to do your part. Your advocacy, combined with
your colleagues, is an essential part of whether we will be
successful or not.
And it is an essential part of our responsibility to our
profession and our patients. Yes, I know your time is very
limited, as is mine. But we forfeit the right to complain
if we have not taken the time to advocate to our legislators on behalf of our patients.
Therefore, we need you to show up at the State
Capitol on March 4 along with hundreds of your colleagues to advocate together on behalf of our patients. To register now, click here. https://www.surveymonkey.
com/r/6H8VPGC. Don’t let people who didn’t go to medical school
dictate how we deliver care to our patients.
I’ll see you on March 4.
MEDICAL SOCIETY OF THE STATE OF NEW YORK
AT YOUR SERVICE
MSSNY’S WESTBURY OFFICE
Main Phone Number......................................516-488-6100
Toll Free Number...........................................800-523-4405
Main Fax Number..........................................516-488-1267
MSSNY Website......................................... www.mssny.org
Extensions for specific services
Alliance.. ........................................................................396
Communications............................................................ 351
Computer Information Systems..................................... 361
Member Benefits/Marketing.......................................... 424
Membership Information............................................... 336
Medical, Educational & Scientific Foundation.............. 350
Office of the Executive Vice President.......................... 397
Ombudsman Claims Assistance..................................... 318
Physician Records/Credentials....................................... 367
Socio-Medical Economics............................................. 332
albany office
Continuing Medical Education...........518-465-8085 ext.17
Public Health Committees.................518-465-8085 ext. 11
Governmental Affairs.....................................518-465-8085
Fax..................................................................518-465-0976
Other Numbers
Committee for Physicians’ Health.................800-338-1833
Dispute Resolution Agency............................516-437-8134
Kern, Augustine, Conroy & Schoppman.......516-294-5432
Page 4 • MSSNY’s News of New York • March 2015
CMS: New Rules for Oversight
CMS recently announced new rules that strengthen oversight of Medicare providers and protect taxpayer dollars from
bad actors. These new safeguards are designed to prevent providers with unpaid debt from re-entering Medicare, remove
providers with patterns or practices of abusive billing and
implement other provisions to help save more than $327 million annually.
CMS is using new authorities created by the Affordable
Care Act to clamp down on Medicare fraud, waste and abuse.
CMS currently has in place temporary enrollment moratoria
on new ambulance and home health providers in seven fraud
hot spots around the country.
The moratoria are allowing CMS to target its resources in
those areas, including use of fingerprint-based criminal background checks.
CMS has demonstrated that removing providers from
Medicare has a real impact on savings. For example, the
Fraud Prevention System, a predictive analytics technology, identified providers and suppliers who were ultimately
revoked, and prevented $81 million from being paid.
These new changes allow CMS to:
1. Deny enrollment to providers, suppliers and owners
affiliated with any entity that has unpaid Medicare debt; this
will prevent people and entities that have incurred substantial
Medicare debts from exiting the program and then attempting
to re-enroll as a new business to avoid repayment of the outstanding Medicare debt.
2. Deny or revoke the enrollment of a provider or supplier if
a managing employee has been convicted of a felony offense
that CMS determines to be detrimental to Medicare beneficiaries. The recently implemented background checks will
provide CMS with more information about felony convictions
for high risk providers or suppliers.
3. Revoke enrollments of providers and suppliers engaging
in abuse of billing privileges by
demonstrating a pattern or practice of billing for services
that do not meet Medicare requirements.
A fact sheet regarding the safeguards is available on CMS’s
webpage. To see the final rule visit: https://www.federalregister.gov/public-inspection
Join MSSNYPAC today at www.mssny.org
mssnypaC
The Flipped Classroom- iClickers
by Robert Goldberg, DO
Executive Dean of the Touro College
of Osteopathic Medicine (NYC)
The administration and faculty of the Harlem
Campus of the Touro College of Osteopathic
Medicine (Touro COM) in New York City
actively strive to advance medical education in
all possible ways. In alignment with the recent
initiative of the AMA, we look for methods and
procedures to improve our curriculum and the
very nature of medical education.
As a new school we have an opportunity to
initiate new methods, as we are free from legacy and traditions that make up the fabric of
many other institutions. We believe that through
dynamic and measured innovation medical education can evolve in unprecedented ways. We
embrace the talents of our medical students,
weaned on electronic media, as we develop new
and exciting means to present material and core
concepts. It is indeed a wonderful time to be in
academics, and in particular, to be a dean of a
medical school during this sea of change.
The concept of the “flipped classroom” is
used here at TouroCOM. Through this platform,
material is accessible to our students where and
when they want to access it. The materials are
reviewed before the student enters the classroom.
Instructors are then ready and able to engage a
class that has been introduced to the subject material so that they at the ready to interact.
Use of iClickers
This column will explore and present another
component of the flipped classroom, the use of
iClickers as a device to measures effectiveness
of knowledge transfer through the use of video
streaming Flipped Classroom model of curriculum delivery. This allows the faculty to measure
micro performance and facilitates the ability of
the administration to formulate student achievement at the macro level.
The flipped classroom model at TouroCOM
incorporates electronic content delivery with
in-classroom clinical correlation and active student engagement. Video recordings made by
the faculty are made available to the students
before classroom time. In class, the instructors
can present clinical scenarios derived, built from
or incorporated in the materials provided to the
class. Following the case presentation, well referenced questions are presented and multiple
choice answers are listed. Students use personal
identifiable iClickers to select their answer. The
instructor then projects an array of the initial
student responses to the class.
Based upon the results, the instructor
addresses the action decision points. If there is
a high correct response rate as demonstrated in
the array, the instructor moves on. If however,
the selections show a slight variance, students
can be called upon to explain their answer. A
discussion ensues.
Not Looking for Just the
“Right Answer”
The purpose of the discussion goes well
beyond selecting a “correct answer.” The discussion invites an instructor to engage students in
discussions among themselves as they explore
the case presentations (along with any lab or
imaging results made available) against the
framework of the digital content viewed in preparation for the class. Students are encouraged
to defend their ideas, learn from their peers and
learn critical thinking skills through the process.
By doing so in the classroom, fellow students
are invited to contribute to the discussion and
the faculty is able to coax wide participation.
After some discussion, the question is posed
again, and the student response then made is
included as a component of the student’s course
grade. Observations and data show that students
are able to draw concise conclusions from the
discussions, as evidenced by the correlation to
the correct answer. Rather than hearing, “No,
you are wrong,” students can explain their reasoning and the faculty can both advise and
encourage while providing real time feedback to
the class. The student responses for this series of
iCLicker responses are electronically recorded,
and are tracked and become part of the student’s
grade; an added benefit of which is greater than
95% attendance for many sessions.
Results Identify Areas Requiring
Clarification
The sessions also allow the faculty to identify core concepts that may require more time
to explain. They will get feedback themselves
as to the effectiveness of their audio visual
recordings, slide bank and reading assignments.
This feedback serves as the driver for edits and
improvements to the electronic curricular content, as well as providing evidence to other areas
of the school, from the curriculum committee to
the admissions committee. Importantly, iClicker
sessions allow for delivery across two campuses
of TouroCOM, while serving as a platform for
distinct in class discussion. Migration from
traditional lectures required faculty effort,
engagement and ultimately ownership of the
system. Now in year three, recording quality
has improved along with student grades, and
satisfaction.
MSSNY welcomes articles discussing topical educational issues from Deans of all New York medical
schools. Please contact Christina Southard, VP Communications Division, at 516-488-6100 or email at
[email protected] if you are interested in submitting an article to the News of New York.
Physician Advocacy Day – An Excellent
Opportunity to Engage with Your
Elected Representatives
Given the added pressure physicians in practice
today feel as a result of the
imposition of so many new
policy changes and new
governmental mandates,
MSSNY’s Physician’s Advocacy Day on March 4th is an excellent opportunity for physicians to engage with their elected representatives in Albany
to express their concern regarding the health policy direction being taken on
the state level. (At press time, Advocacy Day had not yet taken place.)
And with the enormous leadership changes being taken in the Assembly
our advocacy is more important than ever!
Last month, we wrote to tell you about an initiative advanced in the
proposed budget for FY 2015-16 which would enable the development
of corporately owned care settings such as limited service clinics in retail
spaces designed to compete with physician primary care practices. We
also warned that without your intervention other initiatives in the proposed
budget would, if enacted, significantly impose new, costly and burdensome
regulation on the care which can be delivered by physician urgent care and
office based surgical practices.
A new potential threat has arisen in the form of legislation (A.355,
Rosenthal) recently reported by the Assembly Health Committee to the
Assembly floor which if enacted would require physicians every two years
to complete three credit hours of CME in pain management, I-STOP, and
drug enforcement administration requirements for prescribing controlled
substances; appropriate prescribing; managing acute pain; palliative medicine; prevention, screening and signs of addiction; responses to abuse and
addiction and end of life care.
While we must aggressively work to combat these threats we must
also strive toward enactment of legislation which would: enable truth in
advertising by health care professionals; facilitate access by patients to the
physician of their choice and bring about reasonable meaningful relief in
the medical liability premium burdens physicians must bear.
Affecting public change in Albany requires political strength. Political
strength is measured in numbers. With new members we will grow stronger.
It is more important than ever before for physicians to join MSSNYPAC.
If you are a member of MSSNYPAC, thank you! You have shown true
dedication to your profession and patients. But we need so many more
to also contribute. If you haven’t yet joined, please do so immediately by
going to MSSNYPAC under the Governmental Affairs Tab on MSSNY’s
new website (direct link: http://bit.ly/1sylHT7). Together all of medicine
can achieve tangible objectives which protect physician practices and the
patient’s they serve.
Please contribute now. Unless we play our fair part in political action,
we risk losing further ground to those who seek to take away our ability to
control the care we provide to our patients.
Physician Judges Needed For
HOD Poster Symposium
Doctors: If you’re coming to the House of Delegates in Saratoga – or
just live in the neighborhood – and are free on Friday afternoon, May 1,
from 2 – 4:30 pm, please consider participating as a judge at the MSSNY
Resident and Fellow Section Poster Symposium. It’s always an exciting,
lively event! Please contact [email protected] or 516-488-6100 extension 383 if you’re interested.
Physicians prefer facts to speculation.
These are the facts.
• The actions of New York State Government
deeply affect the professional practice of every
single New York physician and the thousands
of patients to whom they provide care. • You can substantially influence whether this
effect is positive or negative through engaging
in collective political action with your
colleagues by joining MSSNYPAC –
the physician’s political action committee. Every physician in New York State CAN AND SHOULD JOIN MSSNYPAC.
Join online or find out more by visiting www.mssnypac.org.
March 2015 • MSSNY’s News of New York • Page 5
Members in the News
Dr. Thomas Named Medical
Director of Rehabilitation
Services for MVHS
John D. Thomas II,
MD has been named
medical director of
Rehabilitation Services
for Mohawk Valley
Health System (MVHS).
Dr. Thomas has served
as medical director for
Rehabilitation Services
John D.
Thomas II, MD at St. Elizabeth Medical
Center (SEMC) since
1998. In this role, he consults to several
national companies and performs independent evaluations and disability reviews. In
addition, Dr. Thomas serves as assistant to
the chief medical officer at SEMC.
Dr. Thomas attended Hamilton College
in Clinton, New York, and the University of
the Northeast Medical School in Tampico,
Mexico. He completed an Internship at
St. Vincent’s Hospital in New York City
through New York Medical College and
a Residency in Physical Medicine and
Rehabilitation at Strong Memorial Hospital
through the University of Rochester School
of Medicine and Dentistry. He is board certified in Physiatry.
A member of MSSNY since 1988, Dr.
Thomas is also active in the American
Medical Association and has served as both
trustee and president of the Oneida County
Medical Society. He is a member of the
American Academy of Physical Medicine
and Rehabilitation, American Academy
of Pain Management, American Academy
of Neuromuscular and Electrodiagnostic
Medicine and the American Academy of
Disability Analysts.
Are You a Disruptive Physician?
Avoid Medicare
Penalties
Reporting PQRS has never been more important. The penalty for not
reporting is, at a minimum, - 2.0% but it could be more. Understanding
the rules can be confusing but is necessary.
Attention MSSNY Members! Save $104
Call (516) 488-6100, Extension 403 or
email: [email protected]
for your MSSNY Member discount code
Use it at the time of submission and receive a
discounted submission rate of $195
Visit Covisint at: www.pqrs.covisint.com or contact
them at 866.823.3958 for more information.
Page 6 • MSSNY’s News of New York • March 2015
Young physicians and residents can learn
“how not to be a disruptive physician,”
as well as the “hidden rules, regulations
and risks” you must watch out for in
medical practice, at the combined YPS/
RFS Annual Meetings, Saturday, March
21, 2015. The meetings will be held at
MSSNY Downstate, 865 Merrick Avenue,
Westbury. Upstate members may participate via webinar at the Monroe County
Medical Society, 132 Allens Creek Road,
Rochester, NY 14618. Webinar participation from home is also an option if you
cannot attend either site in person.
Residents start off with breakfast and
their business meeting at 8:15; YPs join at
10:00 for the presentation and their business meeting. Lunch will be served at both
locations.
These presentations will deal with the
latest in the evolving rules and regulations
governing day to day practice. If you feel
there’s too much information out there to
keep up with, come and find out what’s
really crucial for your practice. Learn best
practices for medical records and malpractice risk management, and the importance
of communication and how to manage
risks attendant to patients and staff. Our
presenter is the ever-popular Michael
Schoppmann of Kern Augustine Conroy &
Schoppmann.
Come to network and to discuss relevant
issues troubling you; consider running
for a leadership position. Register now
[email protected]
Alliance
Save These Dates: March 4, April 30 and May 1!
March 4 is Legislation Day in Albany,
when we lobby our legislators on behalf
of our physician spouses. Registration and
breakfast begin at 8:00 am; the program
begins at 8:30 am in the EGG. You may
register by clicking on this link: www.
surveymonkey.com/r/6H8VPGC.
Please
e-mail Stephanie Cospito at [email protected]
gmail.com if you plan to attend.
And the 79th AMSSNY Annual Meeting
will be held on April 30 and May 1 in
Saratoga Springs, in conjunction with the
MSSNY House of Delegates. We ask your
involvement in both Lobby Day and the
Annual Meeting as a show of support to
your physician spouse. For additional information, please contact Kathleen Rohrer,
AMSSNY Executive Director at [email protected]
mssny.org.
All across the state this winter, Alliance
members have been fund raising for scholarships for students entering health careers
and for local not for profits focusing on
children and health issues. In Onondaga
County, Alliance members are planning a
“Doctors’ Day” event honoring their physician spouses. Doctors’ Day was established
to honor and pay tribute to members of the
medical profession everywhere and to recognize their contributions and continuing
dedication. March 30 was chosen as the official day on which to celebrate Doctors’ Day
because on this day in 1842, Dr. Crawford
W. Long of Jefferson, GA, became the first
physician in history to use ether anesthesia during surgery. The official symbol of
Doctors’ Day is the red carnation.
AMSSNY is proud to support the New
York State Physicians Home. While not
an actual building, this organization helps
physician families in need when a life crisis occurs. Contributions may be sent to
Physicians Home, care of Dr. Joseph B.
Cleary, President of the Physicians Home,
445 Park Ave, 9th Floor, NY, NY 10022
to honor a friend, family member or physician. Our state Alliance contributes a
portion of the funds raised at our Fall
Leadership Conference and our Spring
Annual Membership meeting to this worthy cause. Our Kings County member, Mrs.
Betti Jabbour, has been our liaison to the
Physicians Home for the past ten years. Our
organized counties in the state still contribute annually to the Physicians Home.
Please check out the AMA Alliance
online newsletter, The Alliance in Motion,
and the online resource, Physician Family,
which features topics relating to physicians
and spouses throughout life – from residency to retirement.
Not a member of AMSSNY? Please
contact our Executive Director, Kathleen
Rohrer, at [email protected] or call
1-800-523-4405 for an application. We welcome all spouses and domestic partners of
physicians. See you in Albany and Saratoga
Springs!
Op-Ed: MOC on the Run
by Joshua Cohen, MD, MPH, MSSNY Councilor
In a stunning reversal in February, the American Board
of Internal Medicine (ABIM) announced they would suspend aspects of their maintenance of certification (MOC)
program, adjust reporting of MOC participation, and hold
pricing at or below 2014 rates through 2017. The widely
circulated statement, “We got it wrong and sincerely
apologize” has been abundantly covered by the media and
hailed as a huge victory for those on the front lines of the
anti-MOC battle.
For those certified by ABIM, the celebrations have
begun even as the specifics of the intended changes
remain vague. But what does this mean for those certified
by other boards? What changes might we expect from the
American Board of Medical Specialties (ABMS) which
sets policy for all the boards and was the initial impetus
for the MOC program?
ABIM Statement
Let’s look at the ABMS first. Following the ABIM
statement, ABMS issued a brief and elusive statement.
They stated support for ABIM’s goal of making MOC
more meaningful, but still emphasized the requirements
of the 2015 Standards for the ABMS Program for MOC.
One major component of those standards is a requirement
for boards to include the Part IV practice assessment and
performance improvement. This subtle challenge of the
ABIM announcement may signal an unwillingness of
ABMS to allow ABIM to make the proposed changes.
Stay tuned for a possible battle which may pit the member
board against its parent.
For me and other neurologists, a more pressing question is how our board, the American Board of Psychiatry
and Neurology (ABPN), will pivot following this shocking move by ABIM. Since the launch of MOC, ABPN
has been repeatedly criticized for having one of the most
difficult and confusing MOC programs. I remember reading the requirements over and over when they were first
released, puzzling over what they meant and how I could
comply.
Since that time, ABPN has made a number of changes.
They worked hard to clarify the requirements as diplomates complained they had no idea what they were
supposed to be doing. Their website has a permanent
disclaimer, “ABPN’s MOC Program are subject to change
... consult the ABPN website regularly.”
Some Changes
Last June, I had the incredible opportunity to speak at
a joint conference of the American Medical Association
(AMA) and the ABMS at which 23 of 24 member boards
were in attendance. Some boards shared significant physician-friendly changes they had made or were making to
their MOC programs such as open book exams, providing
test banks for diplomates containing all possible questions that could appear on the recertification exam, or
offering proctored tests from the comfort of one’s home.
The ABPN representative did not share any of their own
best practices or suggest intent to innovate as these other
boards described.
However, a few weeks later, the ABPN announced big
changes to their MOC program. Now, only one feedback
module was needed for Part IV and it could come from
patients or peers. Total CME was reduced, as were the
number of self assessment modules and performance
in practice (PIP) modules. Physicians were no longer
required to log activities in the ABPN folio system.
Changes were positive and helpful, but diplomates
remained aggravated by the cumbersome process. The
ABIM announcement provided new hope that further
change was on the horizon.
Barraged by buoyant diplomates after the ABIM media
storm, the ABPN president and CEO,Larry Faulkner,
MD, e-mailed diplomates this Tuesday with a response.
To many, the tone and approach was surprising.
Dr. Faulkner declared, in bold letters no less, that “most
of the changes now planned by the ABIM are consistent
with policies and practices already in place in the ABPN
MOC program.” He rattled off a bullet-pointed list of
examples of how the programs are similar. Highlighting
the recent ABPN decision to give 3 years of MOC credit
to diplomates who completed subspecialty training and
passed subspecialty exams, he emphasized the reduced
burden on physicians. He indicated that 95% of diplomates pass recertification exams and are given a second
chance to pass before certification is pulled. And he
touted the ABPN’s success in reducing cost, with a 34%
reduction in costs since 2007, including a planned cut of
7% in 2016.
Most significantly, he stressed that no other changes
in the ABPN’s MOC program are planned at this time.
In other words, the fervor around ABIM’s announcement
this week will not push the ABPN to reform its program.
Will diplomates be assuaged by Dr. Faulkner’s assurances? My guess is no. Looking at the ABIM’s new plan,
they go much further than ABPN, especially surrounding the dreaded Part IV. Despite the changes in the past
8 months, the ABPN MOC program continues to have
some of the lowest satisfaction of physicians in any
board. Telling diplomates that you’re doing great and they
should be proud of you may not be ABPN’s best strategy
when ire is so great. Expect more grumbling – for ABIM,
that seemed to do the trick.
This article originally appeared in MedPage Today.
MOC Critics Establish an
Alternative Board Certification
A week after two divergent perspectives on maintenance of certification (MOC) appeared in the New England
Journal of Medicine, the author of the opposition paper has
offered an alternative route to board certification.
In a press release made available January 14, cardiologist
Paul Teirstein, MD, from La Jolla, California, announced
a continued certification program offered by the National
Board of Physicians and Surgeons (NBPAS) that is less
costly and requires a fraction of the time required by the
MOC program offered through the American Board of
Medical Specialties (ABMS). The NBPAS website lists 11
physician board members.
Initially, NBPAS will certify only physicians in internal
medicine specialties and subspecialties and family practice, founding board member Gregg Stone, MD, professor
of medicine at Columbia University in New York City, told
Medscape Medical News. Other specialties will follow, he
said, although he did not specify a time frame.
Cost is $169 for 2-year certification, no matter the number of specialties, NBPAS says. The American Board of
Internal Medicine (ABIM) lists recertification costs of
$2000 to $2500 over the course of 10 years. The NBPAS
website says the application takes less than 15 minutes to
complete.
Will Qualifying Bodies Accept It?
However, the value of the new option is unclear.
Currently, some hospitals and insurers require physicians
to pass MOC, and some physicians see not certifying as a
threat to job security.
“This is a grassroots movement which will grow in acceptance relatively rapidly,” Dr Stone said. “I state that because
of the widespread outpouring of support we’ve received”
for an alternative to MOC.
He said he is confident that the numbers of supporters
will change demands of certification. In the press release,
Dr Teirstein notes that more than 20,000 physicians have
signed an online anti-MOC petition.
He says the requirements for the new certification will
demonstrate lifelong learning after original certification,
but with less cost and time. Among the requirements are
that a physician:
• Must have been previously certified by an ABMS member board
• Must have a valid, unrestricted license in at least one
US state
Must have completed a minimum of 50 hours of continuing medical education within the past 24 months, provided
by a recognized provider of the Accreditation Council for
Continuing Medical Education.
Reprieve Announced: CMS to Shorten 2015 Attestation Reporting Period: from 365 to 90 Days
The Centers for Medicare & Medicaid
Services (CMS) has announced that it intends
to give providers a “reprieve” by issuing a new
rule which would “update” the Medicare and
Medicaid Electronic Health Records (EHR)
incentive programs, and shorten the attestation
period in 2015 from 365 to 90 days, in order to
help “accommodate” those changes.
In a late January blog post (http://ow.ly/
ISBdz), the deputy administrator for innovation and quality and the Chief Medical Officer
(CMO) for CMS, Patrick Conway, M.D.,
stated that CMS is following “multiple tracks”
to realign the Meaningful Use program “to
reflect the progress toward program goals and
be responsive to stakeholder input.” This new
rule would be separate from the proposed rule
implementing Stage 3 of the Meaningful Use
program, which has already been submitted
to the Office of Management and Budget for
review.
It was generally acknowledged, even by
CMS, that the 365 day attestation period presented problems, so the proposed changes
should be welcome. In addition to shortening
the attestation period, CMS is also considering
proposals to modify other aspects of the pro-
gram in order to match long-term goals, reduce
complexity and lessen providers’ reporting burdens, as well as shortening the EMR reporting
period in 2015 to 90 days in order to accommodate these changes.
ABIM Suspends Part
of Controversial
Recertification Process
The American Board of Internal Medicine
(ABIM) has suspended controversial aspects
of its maintenance-of-certification (MOC) program, specifically the “Practice Assessment,”
“Patient Voice” and “Patient Safety” requirements, for at least two years, and apologized for
these provisions.
At a recent AMA meeting, physicians
pointed out that board-certification is becoming a frequent requirement for credentialing by
hospitals, health systems and health insurance
plans. Proposals advanced included asking the
AMA to pass resolutions opposing discrimination on the basis of board certification by
hospitals, employers, state licensing boards,
insurers and government programs which
could restrict a physician’s right to practice
medicine without interference, and asking the
AMA to oppose any mandated MOC unless
research shows a link between certification and
improved patient outcomes.
The ABIM, along with the other twenty-three
members of the American Board of Medical
Specialties, recently changed its recertification
process from one that required an examination
every ten years to one requiring continuous
education and self-assessment. Dr. Richard
Baron, President of the ABIM, said, in a letter posted on the Board’s website, http://ow.ly/
IPzkt, that “ABIM clearly got it wrong. We
launched programs that weren’t ready and we
didn’t deliver an MOC program that physicians
found meaningful.” The ABIM now will not
revoke an internist’s board certification for noncompletion of the program’s suspended aspects.
Allstate Loses Appeal
Over $352 Claim
Allstate Insurance Co. took a matter to arbitration, appealed to a master arbitrator, tried
to have that award vacated by the courts, and
finally appealed to the Appellate Division, but
lost every round. In Matter of Allstate Ins. Co. v.
Westchester Medical Group, “C” was injured in
a motor vehicle accident on February 22, 2011
and sought treatment from a medical group. C
assigned her no-fault benefits to the medical
group, which submitted a claim for $352.81 for
medical services rendered. Allstate maintained
it was not obligated to pay this sum, contending the medical group failed to respond to its
request for “additional verification” to prove the
claim. An arbitrator ruled in favor of the medical group on April 25, 2012, finding that the
medical group did in fact comply with Allstate’s
request, and that Allstate “did not appear to be
acting in good faith.” A master arbitrator confirmed the award on July, 23, 2012. On March
18, 2013, the New York State Supreme Court
in Nassau County denied Allstate’s petition to
vacate the master arbitrator’s award and confirmed the award. Finally, on February 4, 2015,
the Appellate Division, Second Department,
affirmed the lower court’s ruling and held that
Allstate failed to demonstrate any grounds for
vacating the master arbitrator’s award. It has
taken nearly four years for the medical group to
prevail in the litigation and obtain a court order
for payment of the $352 claim.
For more information on the above items,
contact Kern Augustine Conroy & Schoppmann,
P.C. at 1-800-445-0954 or viaemail at [email protected]
DrLaw.com.
March 2015 • MSSNY’s News of New York • Page 7
#BlackLivesMatter – A Challenge to the Medical and Public
Health Communities
Mary T. Bassett, M.D., M.P.H.,
Commissioner, New York City Department of
Health and Mental Hygiene
This article was published on February 18,
2015, at NEJM.org. at http://bit.ly/1AY7KWX
Two weeks after a Staten Island grand jury decided
not to indict the police officer involved in the death
of a black man, Eric Garner, I delivered a lecture
on the potential for partnership between academia
and health departments to advance health equity.
Afterward, a group of medical students approached
me to ask what they could do in response to what
they saw as an unjust decision and in support of the
larger social movement spreading across the United
States under the banner #BlackLivesMatter. They
had staged “white coat die-ins” but felt that they
should do more. I wondered whether others in the
medical community would agree that we have a particular responsibility to engage with this agenda.
Should health professionals be accountable not
only for caring for individual black patients but also
for fighting the racism –both institutional and interpersonal – that contributes to poor health in the first
place? Should we work harder to ensure that black
lives matter?
First, it’s essential to acknowledge the legacy of
injustice in medical experimentation and the fact
that progress has often been made at the expense of
certain communities. Researchers exploited black
Americans long before and after the infamous
Tuskegee syphilis study.4 But there is room for
optimism. Over the past two decades, for example,
we’ve seen a welcome resurgence in social epidemiology and research documenting health disparities.
Whereas stark racial differences in health outcomes
have sometimes inappropriately been attributed
to biologic or genetic differences in susceptibility
to disease or bad individual choices, new methods
and theories are allowing for more critical, nuanced
analyses, including those examining effects of racism. By studying ways in which racial inequality,
alone and in combination with other forms of social
inequality (such as those based on class, gender, or
sexual preference), harms health, researchers can
spur discussions about responsibility and accountability. Who is responsible for poor health outcomes,
and how can we change those outcomes? More critical research on racism can help us identify and act on
long-standing barriers to health equity.
Critical Action
There is also much we can do by looking internally at our institutional structures. Though the U.S.
physician workforce is more diverse than it was in
the past, and some efforts have been made to draw
attention to the value of diversity for improving
health outcomes, only 4% of U.S. physicians are
black, as compared with 13% of the population, and
the number of black medical school graduates hasn’t
increased noticeably in the past decade.5 Renewed
efforts are needed to hire, promote, train, and retain
staff of color to fully represent the diversity of the
populations we serve. Equally important, we should
explicitly discuss how we engage with communities
of color to build trust and improve health outcomes.
Our target “high-risk” communities, often communities of color, have assets and knowledge; by heeding
their beliefs and perspectives and hiring staff from
within those communities, we can be more confident
that we are promoting the right policies. The converse is also true. If we fail to explicitly examine our
policies and fail to engage our staff in discussions of
racism and health, especially at this time of public
dialogue about race relations, we may unintentionally bolster the status quo even as society is calling
for reform.
In terms of broader advocacy, some physicians
and trainees may choose to participate in peaceful
demonstrations; some may write editorials or lead
“teach-ins”; others may engage their representatives to demand change in law, policy, and practice.
Rightfully or not, medical professionals often have a
societal status that gives our voices greater credibility. After the grand-jury decision last November not
to indict the police officer who shot a black teenager
in Ferguson, Missouri, I wrote to my staff noting that
in this time of public outcry, it is important to assert
our unwavering commitment to reducing health disparities. We can all do at least that.
As a mother of black children, I feel a personal
urgency for society to acknowledge racism’s impact
on the everyday lives of millions of people in the
United States and elsewhere and to act to end discrimination. As a doctor and New York City’s health
commissioner, I believe that health professionals
have much to contribute to that debate and process.
Let’s not sit on the sidelines.
As New York City’s health commissioner, I feel a
strong moral and professional obligation to encourage critical dialogue and action on issues of racism
and health. Ongoing exclusion of and discrimination against people of African descent throughout
their life course, along with the legacy of bad past
policies, continue to shape patterns of disease distribution and mortality.1 There is great injustice in
the daily violence experienced by young black men.
But the tragedy of lives cut short is not accounted
for entirely, or even mostly, by violence. In New
York City, the rate of premature death is 50% higher
among black men than among white men, according to my department’s vital statistics data, and this
gap reflects dramatic disparities in many health outcomes, including cardiovascular disease, cancer, and
HIV. These common medical conditions take lives
slowly and quietly – but just as unfairly. True, the
black–white gap in life expectancy has been decreasing,2 and the gap is smaller among women than
among men. But black women in New York City are
still more than 10 times as likely as white women to
die in childbirth, according to our 2012 data.
Physician Peer Reviewers
Independent Contractors
New York Licensed – NY Worker’s Compensation Board Certified
MES Peer Review Services (PRS) is a URAC accredited leading provider of Independent Physician Peer Review services. In response to continued and anticipated growth,
PRS is seeking New York Worker’s Compensation Board Certified Physician Peer Reviewer 1099 Consultants to add to our nationwide panel of peer reviewers. PRS affiliates with reviewers to provide peer reviews for all industries, including, Group Health,
Disability and Workers’ Compensation.
PRS Reviewer Qualifications and Requirements
• Current, unrestricted New York medical
license
• New York Worker’s Compensation Board
Certified
• ABMS or AOA Board Certification
• At least 5 years of active practice in
respective medical discipline
• Current active practice providing direct
patient care (minimum 8 hrs per week)
• Good standing in the National Practitioner
Databanks, Departments of Professional
Regulations, Offices of Inspector General, etc.
• Ability to meet strict turn-around-time
requirements
• Ability to discuss case under review with the
treating provider when required
• Ability to work via the secure PRS web portal,
which observes federal privacy guidelines
Benefits of Working with PRS
• Physician reviewers can work remotely
wherever they have access to the internet
(home, office, etc.)
• Review as few or as many cases as your
schedule permits (steady, daily, reliable work
available for those reviewers who want it)
• S ignificant opportunity for substantial extra
income
• No overhead, no expense
To learn more about this advantageous opportunity
please contact PRS’ National Network Development Supervisor:
Linda French at [email protected]
Page 8 • MSSNY’s News of New York • March 2015
Gaps in Morbidity and Mortality
Physicians, nurses, and public health professionals witness such inequities daily: certain groups
consistently have much higher rates of premature,
preventable death and poorer health throughout their
lives. Yet even as research on health disparities has
helped to document persistent gaps in morbidity and
mortality between racial and ethnic groups, there is
often a reluctance to address the role of racism in
driving these gaps. A search for articles published in
the Journal over the past decade, for example, reveals
that although more than 300 focused on health disparities, only 14 contained the word “racism” (and
half of those were book reviews). I believe that the
dearth of critical thinking and writing on racism and
health in mainstream medical journals represents a
disservice to the medical students who approached
me – and to all of us.
The World Health Organization proclaimed
in 1948 that “Health is a state of complete physical, mental and social well-being and not merely
the absence of disease or infirmity.”3 Today, both
individual and social well-being in communities
of color are threatened. If our role is to promote
health in this broader sense, what should we do,
both individually and collectively? Many health
professionals who consider that challenge stumble
toward inaction – tackling racism is daunting and
often viewed as divisive and requiring action outside our purview. I would like to believe that there
are at least three types of action through which we
can make a difference: critical research, internal
reform, and public advocacy. In reflecting on these
possibilities, I add to nearly two centuries of calls
for critical thinking and action advanced by black
U.S. physicians and their allies.
Examining Institutional Structures
1. Krieger N. Discrimination and health inequities. In: Berkman LF,
Kawachi I, Glymour M, eds. Social epidemiology. 2nd ed. New York:
Oxford University Press, 2014:63-125.
2. Harper S, MacLehose RF, Kaufman JS. Trends in the black-white
life expectancy gap among US states, 1990-2009. Health Aff
(Millwood) 2014;33:1375-1382
3. Preamble to the constitution of the World Health Organization as
adopted by the International Health Conference, New York, 19-22
June, 1946: signed on 22 July 1946 by the representatives of 61
States (official records of the World Health Organization, no. 2, p.
100) and entered into force on 7 April 1948 (http://who.int/about/
definition/en/print.html).
4. Washington HA. Medical apartheid: the dark history of medical
experimentation on black Americans from colonial times to the
present. New York: Doubleday, 2006.
5. Diversity in the physician workforce: facts & figures. Washington, DC: Association of American Medical
Colleges,
2014
(http://aamcdiversityfactsandfigures.org/
section-ii-current-status-of-us-physician-workforce/).
Physicians Must Start Using
Revised 855R Applications
Medicare Administrative Contractors (MACs) will require the use of
the revised CMS 855R (Reassignment of Benefits) application as of May
31, 2015.
The revised CMS 855R were available for use on the CMS website
as of December 29, 2014. However, MACs may accept both the current
and revised versions of the CMS 855R through May 31, 2015. After May
31, 2015, MACs will return any newly submitted CMS 855R applications on the previous version (07/11) to the provider/supplier with a letter
explaining the CMS 855R has been updated and the current version of
the CMS 855R (11/12) must be submitted.
The revised CMS 855R has been streamlined and some sections have
been re-ordered for clarity. It includes an optional section for primary
practice location address. This information is shared with other programs, such as Physician Compare, to help beneficiaries identify where
their physicians are primarily practicing and must be an address affiliated
with the group/organization where the benefits are being reassigned.
Cuomo’s Health Spending Plan
(Continued from page 1)
in outpatient settings, including OBS practices and
ASCs for the purpose of (a) identifying the types of procedures performed and the types of anesthesia/sedation
administered in such settings; (b) considering whether it
is appropriate for such procedures or anesthesia/sedation
to be performed in such settings; (c) considering whether
settings performing such procedures or administering
such anesthesia/sedation are subject to sufficient oversight; (d) considering whether settings performing such
procedures or administering such anesthesia/sedation
are subject to an equivalent level of oversight regardless of setting; and (e) making recommendations to the
department regarding the foregoing
• Authorization of the Commissioner to utilize methodologies of reimbursement that are value based. Specifically
authorizes a DSRIP performing provider system (PPS)
or subset of providers to arrange by contract for the
provision of services in exchange for value based
reimbursement
• Appropriation for MSSNY’s Committee for Physicians’
Health $990,000
• Elimination of existing fees for requesting arbitration of
workers compensation cases and certain registration fees
for radiologic sites
• Establishment of a private equity pilot program, allowing up to five business corporations to make private
capital investments to assist in restructuring health care
delivery system
• Establishment of a $1.4 billion capital construction
fund to build a new hospital in Brooklyn and to assist
in capital construction and health care integration across
upstate New York
The Division of Governmental Affairs will continue
to review and update our members as more specifics on
these proposals become available. Open Letter to
MSSNY Physicians
Who Signed Up for
Veterans Choice Program
We thank you for your willingness
to assure our veterans can receive the
timely quality care they deserve. As you
may be aware, Congress recently enacted
a law with strong bi-partisan support
that would make it easier for veterans to
receive timely care by a non-VA physician. The new program, referred to as
the “Veterans Choice Program,” enables
the VA to enter into provider agreements
with non-VA physicians in the community to deliver care to veterans who meet
the following eligibility criteria: • Veterans who are unable to receive
timely care – defined as wait times of
more than 30 days.
• Veterans who live too far away from
a VA facility – defined as more than
40 miles.
Set to sunset in August 2016, the
Veterans Choice Program will wind down
as the VA ramps up efforts to rebuild its
workforce and improve accountability
at its facilities. To read an AMA summary of this new program, please click
here (summary of the Veterans Choice
Program Interim Final Rule )
The AMA has also provided information how physicians can apply to
participate in this Veterans Choice
Program. Health Net and TriWest are
the two VA contractors that are implementing the Veterans Choice Program.
Physicians interested in delivering care
through the Veterans Choice Program
must join the Health Net or TriWest network of non-VA providers.
Follow these steps to apply:
Step 1: Use the Veterans Choice
Program Contractor Map to identify
which VA contractor is administering the
Veterans Choice Program in your locale.
Health Net is the entity operating the
program in New York State. Step 2: Review the Conditions of
Participation to verify that your practice is configured to participate in the
Veterans Choice Program.
Step 3: Go to the contractor website
to complete the Participating Provider
Agreement and join its provider network.
Join the Health Net Network® here. Please contact Regina McNally, VP
of MSSNY’s Socio-Medical Economics
Division, at [email protected] if you
have further questions about this new
program.
March 2015 • MSSNY’s News of New York • Page 9
WHO’S IN CHARGE?
Four Ways That Most Doctors Harm Their Online Reputation
me dic “Thi s h e r
e’s
at i
o f ap o n s yo u’re a l i s t o f ap
p
p e r f o ro ve d p ro a l l o we d t p ro ve d
rm , w
o di sp
c e du r
en
es
it
ch a rg h t h e amo yo u’re a l l s e , a l i s t
u
o
e f or
e ve r y n t yo u’re a we d t o
l l o we
t hi ng
d to
yo u d
o.”
Consider this – 83% of patients use Google
to find a doctor. But according to BetterDoctor.
com physician marketing expert Dutch Rojas,
thousands of doctors hurt their “Google” reputations without even knowing it by committing
the following four mistakes:
Mistake #1: Not Having a Personal Website
Even if you’re included on your practice’s
website, having your own personal website is
imperative because prospective patients will
often Google your name (not the name of your
practice) and personal sites can show up higher
in Google results.
Mistake #2: Ignoring Review Sites
You want to ensure that your name, address,
specialty, and phone number are up to date so
that you don’t lose patients to incorrect contact
information on third-party sites.
Seems ridiculous doesn’t it? But it’s no
more unthinkable than a legislator or
an insurance company executive with
the power to create legislation that
will dictate how a physician can treat a
patient. The MSSNY is working hard to
make sure that doesn’t happen, but we
need your support.
Help us keep the healing in
the hands of the healers.
Mistake #3: Using Bad Photos (Or None at All)
High quality photographs are usually a
patient’s top request (try head shots on a neutral background) because it makes patients more
comfortable, conveys warmth and professionalism, and builds trust.
Mistake #4: Doing Your Own Copywriting
A professional copywriter can help bring
your story to life, propel you higher in Google
search rankings (you need pages of 250 words
or more) and allow you to show how you’re different from other physicians.
Additionally, Rojas suggests that devoting 10 minutes per week to “Googling
yourself ” can reveal online reputation issues
before they become a big problem. Just like a
preventative health checkup, regularly monitoring your “Google health” can work wonders.
BetterDoctor.com provides a quick and easy
tool that empowers doctors to build and manage their online presence.
The Financial Cost of Smoking in New York
(1=Lowest, 25=Avg.)
• Total Cost per Smoker (Rank) – $1,982,856 (49th)
• Tobacco Cost per Smoker (Rank) – $1,527,924 (50th)
• Health Care Cost per Smoker (Rank) – $208,467 (46th)
• Income Loss per Smoker (Rank) – $233,894 (36th)
• Other Costs per Smoker (Rank) – $12,570 (44th)
For the full report, please click here.
Medical Society of the State of New York
www.mssny.org
Westbury Headquarters:
865 Merrick Avenue, Westbury, NY 11590 • (516) 488-6100
Who's in Charge.indd 1
Page 10 • MSSNY’s News of New York • March 2015
8/19/14 9:39 AM
Not a MSSNY Member?
Join Now: 516-488-6100
I-STOP: Beyond the Mandate
e-prescribing solutions in the marketplace. As
a result of that analysis, MSSNY identified
DrFirst as the vendor delivering the most effective stand-alone e-prescribing platform in terms
of clinical workflow, ease of use, and cost-effectiveness. MSSNY has partnered with DrFirst to
provide MSSNY members with legend drug
and controlled substance e-prescribing capabilities bundled together for a special discounted
price.
(Continued from page1)
both legend drugs and controlled substances
lies in meeting Meaningful Use requirements
in light of the recent schedule change by the
DEA for hydrocodone combination products
(HCP) from a Schedule III to Schedule II controlled drug. The impact of this change is that
with no call-ins or refills permitted, providers
are required to create a greater number of new
prescriptions for products like Vicodin, which
as a result will increase the total number of prescriptions issued. Since Meaningful Use stage
2 requires that more than 50-percent of all prescriptions must be transmitted electronically, an
increase in paper prescriptions may push providers out of Meaningful Use compliance.
MSSNY Endorses DrFirst
Identifying Doctor Shoppers
The most significant advance that e-prescribing gives providers is in the improvement to the
quality of patient care. Access to patient medication history during the prescribing process
gives providers better information about home
medications. Combining medication history
with automated clinical decision support such
as formulary compliance, dose checking, drugto-drug, drug-to-allergy and drug-to-condition
alerts helps providers avoid over-prescribing, or
prescribing medications that may cause adverse
drug events. Accessing patient medication history at the point of e-prescribing also helps
providers more easily identify potential doctor shoppers, thus helping to stem prescription
misuse.
The advantages of e-prescribing for patients
are also quite significant. In addition to the
patient safety benefits outlined above, patients
benefit from the ease and efficiency of e-prescribed medications. Having medications
ready when the patient arrives at the pharmacy,
with the formulary compliance check already
completed by the physician, and any prior authorization activities completed in advance, there
are fewer hurdles for patients. This convenience
translates into better medication adherence as
well since there is virtually no delay in patient
access to their initial prescription.
Get Ready to E-Prescribe Now
The benefits of universal e-prescribing are
numerous, which is why MSSNY believes
its members should pursue implementation
of e-prescribing for both legend drugs and
controlled substances now, regardless of the
CLASSIFIED ADVERTISING
Classified ads can be accessed at
www.mssny.org. Click classifieds.
APRIL 2015 ISSUE CLOSES March 18
$150 per ad; $200 with Photo
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I-STOP e-prescribing mandate deadline. The
value to practitioners and patients is clear, and it
is important that practices deploy an e-prescribing solution now to ease the transition and avoid
potential hiccups as they transition from paperbased scripts to electronic scripts. Physicians
also must go through the DEA – mandated
identity proofing process before being permitted to prescribing controlled substances
electronically.
To support and guide its members, MSSNY’s
healthcare information technology committee
conducted a thorough analysis of numerous
The MSSNY-endorsed software includes
DrFirst’s Rcopia® legend drug e-prescribing
and DrFirst’s EPCS GoldSM 2.0 controlled
substance e-prescribing platforms, packaged
for MSSNY as a stand-alone, web-based solution. Providers using Rcopia and EPCS Gold
will be able to e-prescribe legend drugs or controlled substances within a single workflow. The
software will also support doctors with realtime prescription monitoring, instant access to
medication histories for their patients, patientspecific formulary data, and clinical alerts
such as drug-drug and drug-allergy interaction
warnings. DrFirst will guide MSSNY members
through the identity proofing and authentication processes that are required by the Drug
Enforcement Agency (DEA) to allow a doctor
to prescribe controlled substances electronically. The e-prescribing software also includes
DrFirst’s Patient AdvisorSM service, which
helps doctors monitor and improve patient
adherence to medication therapy, and allows
doctors and their staff to process and complete
medication prior authorizations electronically,
right within the e-prescribing workflow.
For more information, MSSNY members can
call DrFirst’s MSSNY E-prescribing hotline at
866-980-0553 or visit www.drfirst.com/mssny.
OBITUARIES
ANUNTA, Boonchuay; Buffalo NY. Died December 26,
2014, age 73. Erie County Medical Society.
BLUM, Edmond; New York NY. Died January 20, 2015, age
84. New York County Medical Society.
HENRIKSSON, Jan; Roslyn NY. Died December 31, 2014,
age 46. Nassau County Medical Society.
KIRKPATRICK, Harold James; Glens Falls NY. Died January
07, 2015, age 75. Warren County Medical Society.
LEHRFELD, Jerome Warner; Commack NY. Died January
07, 2015, age 83. Nassau County Medical Society.
MOUSAW, David F.; Glens Falls NY. Died January 02, 2015,
age 69. Warren County Medical Society.
NAGEL, Richard J.; Orchard Park NY. Died January 21,
2015, age 86. Erie County Medical Society.
OLSON, John Peter; Rochester NY. Died November 27, 2014,
age 84. Monroe County Medical Society.
PENNISI, Anthony Mario; Rockville Centre NY. Died
January 03, 2015, age 87. Nassau County Medical Society.
ROMANOWSKI, Richard R.; Buffalo NY. Died January 15,
2015, age 82. Erie County Medical Society.
ROSTEING, Horace Michael; Williamsville NY. Died
December 24, 2014, age 84. Erie County Medical Society.
SLAFF, Bertram A.; New York NY. Died January 14, 2015,
age 93. New York County Medical Society.
WONG, Santiago Alejan; Medford NY. Died April 09, 2013,
age 72. Suffolk County Medical Society.
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March 2015 • MSSNY’s News of New York • Page 11
Medical Audits: Top Ten Tips for Physicians to Anticipate, Respond and Protect Their Practices
(Continued from page1)
of a benchmarking analysis can therefore provide physicians
with information critical to tailoring a defense to an audit or
a repayment demand. Of particular importance, physicians
should understand the proper benchmark for their practice –
the more sub-specialized the practice, the more aberrant the
physician’s coding may appear when compared with other
physicians, even within his or her specialty. For example, a
trauma surgeon’s billing and coding will vary dramatically
from that of a general surgeon, but a payer’s audit software
may compare all surgeons regardless of sub-specialty. Proper
benchmarking can also have implications for other payer
policies impacting physicians’ bottom line, such as physician
designation programs and tiered networks. One way to assess
whether a practice’s coding and documentation is consistent
with its clinical cases is peer review by other physicians in the
practice. Physicians armed with such knowledge, before an
audit or demand for repayment, are better equipped to effectively respond when faced with an audit.
Ensure that Coding and Billing Practices
Comply with Coding Rules and Relevant
Medical Policies Before an Audit Occurs
Physicians should regularly conduct random audits of their
coding and billing practices to ensure that they comply with
CPT and other coding rules and the relevant medical policies of the payers to whom they submit claims. As previously
stated, the mere fact that a physician’s utilization of a particular code is out-of-line with his or her specialty does not
mean that he or she is coding inappropriately. It may simply
reflect that particular physician’s patient mix or subspecialty.
In addition, physicians often take false comfort in the codes
applied by their electronic health record (EHR) systems. It
is, however, incumbent on physicians to ensure that their
coding and billing practices, including codes and information populated by EHR systems are compliant. To do this,
EHR systems should not be set at default levels, physicians
should not blindly copy and paste between medical records
and a patient’s history and diagnosis codes should relate to
conditions addressed on the date of service. Lastly, payers,
including Medicare Administrative Contractors (MACs),
are increasingly performing pre-payment audits. Although
pre-payment reviews can be burdensome, physicians can use
them to engage in dialogue with a payer’s medical director to
identify why they have been selected for pre-payment review,
to ensure that their coding and 4 billing practices comply with
a payer’s rules and medical policies, and, where appropriate,
to challenge and potentially correct a payer’s application of
CPT, other coding rules or Medical Policies.
Determine on Whose Behalf an Audit is
Being Conducted and The Type and Scope
of the Audit Before Responding
Third party payers frequently contract with outside vendors
to review medical records and to conduct audits, sometimes
referred to as “proxy” audits. Unfortunately, these companies
do not always identify the payer on whose behalf they are
working or the type and scope of the audit – critical information which physicians have the right to know. If either the
name of the payer or the type and scope of the audit are not
readily apparent from a communication requesting medical records or initiating an audit, physicians should ask and
should document the answers. Such information is essential
not only for physicians to know what type of audit they are
facing but also to confirm that the entity seeking access to
the records is legally authorized to access them under HIPAA
or any more stringent state law. Depending on the type of
the audit, physicians should also carefully consider retaining
counsel or other consultants. Retaining counsel is generally
recommended when facing audits which could result in findings of fraud, such as Medicare Unified Program Integrity
Contractor (UPIC) and Zone Program Integrity Contractor
(ZPIC) audits.
Pay Attention to Deadlines and Procedures
Physicians should designate an individual responsible
for responding to medical audits and for keeping physician
informed of its progress. Among other things, this individual should calendar all deadlines and document and retain
all communications between the practice and the auditors.
If a request for medical records or an audit letter includes a
deadline for providing the requested information, the practice
should either timely respond or immediately seek an extension.
In addition, if the request does not specify the deadline, the
designated responder should ask. This is critical because failure to understand and meet deadlines can have consequences.
Page 12 • MSSNY’s News of New York • March 2015
For example, failure to respond to requests for records within
45 days in a MAC pre-payment review can result in payment
denial for the claim. In addition, failure to appeal a Recovery
Audit Contractor (RAC) audit finding within the first 30 days
can result in recoupment pending appeal, even if an appeal is
subsequently filed within the 120-day appeal window. This
practice’s designated individual should also verify how and
where records are to be submitted. For example, can they be
submitted electronically, or, must paper copies be provided?
If the practice elects to retain an attorney or other consultant,
the practice’s designated individual can also be the point of
contact for communications with these outside professionals.
Ensure that Medical Records are Complete
Before submitting medical records for review, physicians
must verify that the records are complete, including adding
any documents or test results that had not yet been added to
the medical chart. This is critically important because many
payers do not allow physicians to supplement the records after
the fact, which can result in overpayment demands based on
incomplete information. Physicians should review the records
and include any explanation or support for any unusual services or tests. In addition, the individual submitting the
records should verify that no information has been cut off or
omitted in copying, including verification that both sides of
two-sided copies were copied. Finally, the individual designated to oversee the audit should retain copies of all records
submitted to ensure that any requests for repayments or audit
findings are accurate based on the records submitted.
When an Auditor’s Overpayment Demand
is Based on Extrapolation from a Claims
Sample, Ensure that the Methodology
is Fair
Some payers use extrapolation, the calculation of an
alleged overpayment amount based on a review of a sample
of a physician’s records. Recovery Auditors (RACs) may not
use extrapolation unless they determine that a provider has
a sustained or high error rate OR unless an educational corrective action by the MAC has failed to correct any errors.
However, a RAC’s determination to use extrapolation cannot
be challenged on appeal. Extrapolation is commonly used by
commercial payers, using a variety of different formulas. If an
auditor or payer demands repayment based on an extrapolation,
physicians should endeavor to determine if the claims sample
used was randomly selected and the extrapolation methodology is fair. A complete discussion of extrapolation and testing
for fairness is included in PAI’s White Paper, Medical Audits:
What Physicians Need to Know, which is posted at www.physiciansadvocacyinstitute.org. However, there are some things
that a physician can easily do to gauge the fairness of an overpayment amount calculated based on extrapolation.
Ensure that Outliers were Removed
from Calculation
For example, physicians should ensure that all outliers were
removed from the calculation, that zero paid claims were
removed from the calculation and that underpaid claims, rather
than just allegedly overpaid claims, were included in the calculation. Physicians who believe that underpaid claims were not
included in the sample or calculation should consider requesting a 100% claims review.
Although this can be burdensome for both physicians and
payers, it can prevent unfair extrapolation from a small, possibly unrepresentative claim sample, and can also help identify
underpaid claims, thereby reducing the amount demanded, or,
in some cases, eliminating the demand altogether.
Verify Audit Findings
Audit findings are often erroneous. In fact, a Department of
Health and Human Services Office of the Inspector General
(OIG) report issued in August 2013 based on a review of
2010 and 2011 claims found that approximately 44% of all
appealed RAC contractors’ findings of alleged overpayments
are overturned at the third level of appeal (the ALJ level).
(Medicare Recovery Audit Contractors and CMS’s Actions
to Address Improper Payments, Referrals of Potential Fraud,
and Performance, OEI-04-11-00680, p. 11). Other reports
have found even higher success rates for providers on appeal.
Therefore, physicians should never assume that an auditor’s
findings are accurate. Rather, they should verify the substance
of any findings – for example whether a particular code was
billed correctly, whether a patient’s diagnosis supported a particular procedure, or whether a required pre-authorization was
obtained. They should also check the auditor’s math. When
faced with a demand for repayment, physicians often believe
that it is easier to just pay the amount demanded. Although that
may save time in the shortrun, physicians taking that route not
only may pay more than is legitimately owed, but also may be
subject to continued demands for re-payment for the same reason in the future. Therefore, if a physician disagrees with the
auditor’s findings after objectively reviewing the audit report,
he or she should strongly consider filing an appeal.
Understand Appellate Rights and
Procedures and Appeal All Erroneous
Adverse Findings
Physicians should understand a payer’s appeals procedures
and should timely file any appeal of an erroneous audit finding. Understanding a payer’s appeals procedures is important
and can have a significant impact the ultimate result of the
audit. For example, the RAC program allows physicians 120
days to file a first level of appeal from a demand for overpayment (the “redetermination” level of appeal). However,
unless the first level of appeal is filed within 30 days, the physician will be subject to automatic recoupment of the amount
demanded on the 41st day, even if an appeal is subsequently
timely filed. Therefore, physicians who believe they have
a strong case on appeal should consider filing it within 30
days to avoid recoupment. This is particularly important in
light of CMS’ moratorium on submitting appeals to the ALJ
level until the current backlog is cleared. (possible cite to Ed
Gaines article Significance of the Delays in the Assignment of
Administrative Law Judges in Medicare Part B Appeals). As
a further example, the RAC appeals process allows for informal discussions as a supplement to the formal appeals. These
informal discussions can be useful in having audit findings
overturned without having to complete the formal appeals
process. Even when audit findings are not changed as a result
of informal discussions, they can be useful in understanding
the RAC contractor’s reasoning. Physicians should be aware,
however, that these informal discussions do not alter any of
the deadlines for filing appeals.
Include All Necessary Information to
Refute Erroneous Audit Findings on Appeal.
An appeal of audit findings should be written as if the individual deciding the appeal knows nothing about the audit or
the auditor’s findings. Each and every audit finding being
appealed should be restated and refuted. If a physician is
relying on CPT coding policy or specialty society coding
guidance on appeals regarding coding, citations to or copies
of these materials should be included in the appeal. Likewise,
if a physician is relying on medical literature to refute a finding of lack of medical necessity, a citation to or a copy of the
study or article should be included. A summary of a physician’s arguments on appeal should also be included.
Address Any Identified Coding
and Billing Problems
There are times when an audit identifies genuine coding
and billing issues. In such cases, physicians should take
immediate steps to correct the identified issues and show the
payer the remedial measures that have been implemented. For
example, a staff member or an electronic medical record system may have applied an incorrect code in certain instances.
Or, the correct code may have been applied, but the documentation was not sufficient to support the code. Depending
on the payer, the situation of the physician practice, and the
circumstances of the demand for repayment, payers may be
willing to negotiate reduced payment amounts and/or a plan
allowing payment over time. Therefore, if a physician can
identify the source of a problem and fix it, a payer may be
satisfied that the issue will not recur and as a result be more
willing to negotiate a reduced re-payment amount and/or a
reasonable payment plan.
The information provided in this article constitutes general
commentary and information on the issues discussed herein
and is not intended to provide legal advice on any specific
matter. This article should not be considered legal advice and
receipt of it does not create an attorney-client relationship.
PAI is a not-for-profit 501(c)(6) advocacy organization
whose mission is to advance fair and transparent payment
policies and contractual practices by payers and others in
order to sustain the profession of medicine for the benefit of
patients.
ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing
emergency care through continuing education, research and
public education. Headquartered in Dallas, Texas, ACEP
has 53 chapters representing each state, as well as Puerto
Rico and the District of Columbia. A Government Services
Chapter represents emergency physicians employed by military branches and other government agencies.