News & Media
MSMS Board of Directors meet, discuss legislation and payer issues
Earlier this week, the Michigan State Medical Society (MSMS) Board of Directors met to discuss the current legislation and payer issues. Below are some of the highlights:
Legislation:
SB 826 Impose licensure on "naturopathic physicians"
Introduced by Sen. Rick Jones (R) on February 15, 2018
To impose licensure and regulation on "naturopathic physicians," with license fees, education requirements, and more. The bill defines "naturopathic" medicine as "a system of practice that is based on the natural healing capacity of individuals".
The MSMS Board of Directors voted unanimously to oppose Senate Bill 826.
HB 5223 Impose new state reporting mandate on drug companies
Introduced by Rep. Hank Vaupel (R) on November 7, 2017
To, among other things, impose a new mandate on manufacturers of prescription drugs that they must file detailed reports with a state agency on the costs associated with developing and marketing prescription drugs with a wholesale acquisition cost higher than $200 or an increase in cost of 25% or more over 5 years or 5% over the previous calendar year.
The MSMS Board of Directors voted unanimously to support House Bill 5223.
Pharmacy benefit manager transparency legislation
Likely introduction by Rep. Hank Vaupel (R) in fall 2018
Another bill anticipating introduction in the fall would require pharmacy benefit managers (PBM) to register with the state Department of Insurance and Financial Services (DIFS) and report information to DIFS related to rebates received. The legislation would also address pharmacy "gag clauses" -- contractual conditions often set forth by PBMs that prevent a pharmacist from sharing information on lower cost medications or alternative payment options with a customer.
The MSMS Board of Directors voted unanimously to support proposed pharmacy benefit manager transparency legislation.
MDPAC: The Board of Directors discussed the physicians who are running for elected offices in 2018 and the importance of physicians to run for office. It was also recommended that MSMS cultivates physician leaders who wish to run for elected office and encourage them to start at the local level to gain experience to serve in higher offices. If you are interested, please contact Christin Nohner. Please consider contributing to MDPAC today.
Health Care Delivery and Education:
BCN Down Coding. Blue Care Network (BCN) is repricing claims submitted for higher level evaluation and management codes based solely on the ICD 10 code, without reviewing the medical record for the visit. MSMS has advocated changes to the appeals process, specifically in the cases when there is a difference of opinion between the treating physician and the health plan physician regarding medical necessity. MSMS met with the medical director earlier this month. BCN noted they would review their policy again.
BCBSM Modifier 25. Earlier this spring, BCBSM announced a policy change that E/M services billed with Modifier 25 will pay at 80 percent when billed with a surgery on the same day by the same physician. Modifier 25 is used to indicate that a significant, separately identifiable E/M service was performed by the same physician on the day of a procedure. It unbundles the two separate services.
BCBSM's rationale for the reduction in reimbursement of the E/M service is to eliminate paying for the overlap in the E/M service and the procedure. MSMS explained the RVS Update Committee (RUC) already considered overlap when valuing the CPT codes and subsequently, removes the valuation for the overlap components. After thoughtful consideration, BCBSM determined that implementing this policy would not be appropriate based on this information.
LARC. A large stakeholder group of health care associations requested that Medicaid consider revising its funding on long-acting, reversible contraceptives (LARC) immediately post-partum. In May, they announced a new policy to establish hospital reimbursement for immediate postpartum LARC implants separate from the maternity Diagnosis Related Group (DRG) payment. Effective for dates of service on or after October 1, 2018, separate reimbursement will be available for LARC devices when the device is provided immediately postpartum in an inpatient hospital setting prior to discharge.
BCBSM Audit Process. Blue Cross Blue Shield of Michigan (BCBSM) is aligning their audit process across the company. As a part of this restructuring, BCBSM will administer all audits for all products in the same manner except for Blue Care Network. They will utilize an external vendor to review claims data and determine outliers based on proprietary formulas. This vendor will perform the initial audit. All second level appeals will be sent directly to Physicians Review Organization, an URAC accredited Independent Review Organization. Previously, most of these audits were reviewed internally by BCBSM staff. The timeline for BCBSM implementation is later this summer.