OMA Stat News
December 1, 2009
Volume 39, No. 12
CMS Proposed Rule Implements Dec. 31
Compliance Deadline for Medicare Advantage Fraud and Abuse Training
CMS published a proposed Part D rule in the Oct. 22 Federal Register that addresses aspects of the fraud and abuse training issue under Medicare Advantage. It appears that the Medicare Fraud, Waste and Abuse rule proposes that if physicians have their own Medicare provider number, they do not have to take the fraud and abuse training. The following proposal was included in the rule:
Providers of services must have a provider agreement with us that permits them to provide services under original Medicare. Requiring an additional fraud, waste, and abuse certification, as was clarified in the response to comments in the December 5, 2007 final rule, imposes an additional unnecessary burden on these Medicare providers. Therefore, we are proposing to modify this paragraph to state that providers who have met this requirement through enrollment into the Medicare program are deemed to have met this training and education requirement.
The AMA notes that this is only a proposed rule and it does not become law until a final rule is issued and new instructions are provided to MA plans. In the meantime, the AMA is planning to comment on the proposed rule. Both the AMA and OMA recognize that, regardless of these proposed changes, physicians continue to be very concerned about the Dec. 31, 2009 compliance date, and the AMA has contacted senior officials at CMS requesting that they provide some information to MA plans and physicians that would allay their concerns about the need to comply with the training deadline. The OMA will monitor the status of this proposed rule and will keep members updated on this matter. In the mean time, if physicians are providing services for MA plans, the OMA recommends checking with the MA plan's provider representative regarding required MA compliance training.
CMS Extends 2010 Annual Participation Enrollment Program
According to the AMA, CMS has extended the 2010 Annual Participation Enrollment Program end date from Dec. 31, 2009 to Jan. 31, 2010. This extension has been granted due to recent revisions made to the 2010 Medicare Physician Fee Schedule. However, the effective date for any participation status change during the extension period remains Jan. 1, 2010, and these status changes will be in force for the entire year.
Contractors will accept and process any participation elections or withdrawals that are received or post-marked on or before Jan. 31, 2010. The participation agreement (CMS-Form 460) is available on your contractor's website with the participation enrollment instructions.
Federal Health System Reform Update
Congress continues to inch legislation forward, and has now moved a reform package further than ever before. That being said, the Senate still needs to debate and vote on its version, and then both the House and the Senate versions will need to go to a conference committee for final amendments. On Nov. 7, the House passed HR 3962, the "Affordable Health Care for America Act," by a vote of 220-215. The House bill includes insurance market reforms, an individual and employer mandate, a national health insurance exchange and a public option.
On Nov. 21, the Senate voted 60-39 to begin debate on its version of health system reform and formally consider HR 3590, the "Patient Protection and Affordable Care Act." The Senate will begin debate on their bill following the Thanksgiving recess. While the Senate version has some improvements like eliminating the five percent payment cut for "outliers" and reducing the Medicare/Medicaid enrollment fee for physicians, there are still some concerns regarding a proposed independent Medicare commission and a one-year deferment of the Medicare physician payment cuts rather than a permanent replacement of the flawed Sustainable Growth Rate formula.
The OMA continues to provide comments to help guide our congressional delegation in formulating a final proposal that will reflect what is important to our members and the patients they serve. Our comments are based on our existing health reform principals and reference the provisions we support, provisions we oppose and highlight problems that still need attention.
House Passes Permanent Repeal of SGR
On Nov. 19, the House passed HR 3961, a bill that repeals the current Medicare physician payment formula, and replaces it with a new framework. The new formula creates two updates: GDP + 2 for Evaluation and Management services and GDP + 1 for other services. The Senate failed to pass a permanent repeal in October and now needs to find a compromise for the current proposal to make its way to the President's desk.
H1N1 Vaccinations Still Limited to Priority Groups
Between September 1 and mid-November, 49 people in Oregon died of influenza-like illness and 1,183 have been hospitalized throughout the state. As demand for influenza vaccines continues to outpace supply distribution, immunization against novel H1N1 is still limited to the priority groups most at risk: pregnant women, children under age 5, health care providers, people caring for infants under 6 months old, and people age 5 to 64 with underlying health conditions. Oregon has also added frontline law enforcement and safety workers to the priority groups.
Self-declaration is the current method of determining who belongs to these priority groups. Those seeking H1N1 flu vaccination are not required to present documentation, such as a note from their physician, indicating that they are among a priority group.
Shipments of H1N1 vaccine from private drug manufacturers arrive in Oregon every week, and in late November, Oregon's cumulative total allocation was 664,904 doses. In total, Oregon has received enough H1N1 vaccine to immunize about 30 percent of the total priority population in the state.
As vaccine supplies remain somewhat scarce, HHS has developed a Flu Shot Locator to help people find clinics and pharmacies administering flu vaccines in their communities. Furthermore, there are no residence requirements for vaccine administration, so citizens can be vaccinated at a clinic outside their home county or state. The Flu Shot Locator can be found at The OMA continues to add resources and updated information to our H1N1 Flu Resource page at
Live Attenuated Influenza Vaccine a Safe and Effective Choice for Health Care Workers
The Oregon Public Health Division reminds health care workers that live attenuated influenza vaccine, also known as LAIV or FluMist®, offers safe and effective protection against seasonal and H1N1 influenza. LAIV is safe for healthy, non-pregnant people between age 2 and 49, including those who may come in contact with infants under 6 months old or persons with chronic health conditions or a weakened immune system.
Health care workers, besides those with patients requiring protective isolation, are encouraged to use LAIV, as long as they are healthy and under the age of 50, as this will help conserve inactive influenza vaccine for those who are unable to take the live attenuated vaccine.
While pregnant health care workers should not themselves use LAIV, they can safely administer the live attenuated vaccine to patients without special precautions, such as gloves.
Safety and Efficacy of LAIV
In clinical studies, transmission of the live attenuated vaccine virus to close contacts has been very rare, and infection is unlikely to result in influenza-like symptoms, as the viruses are attenuated.
Side effects associated with LAIV in adults include runny nose, headache, sore throat and cough, and children may experience a fever. Clinical trials of live attenuated vaccine saw few side effects in children 24 months and older, while children under 24 months of age experienced increased wheezing and hospitalization, compared to those receiving the inactivated influenza vaccine. Less than one percent of LAIV recipients, including adults and children, experience serious adverse reactions, and no instances of Guillain-Barré Syndrome have been reported.
During the 2007-2008 flu season, a comparative efficacy study among healthy adults found that inactivated vaccine prevented 68 percent of culture-confirmed influenza infections, while LAIV prevented 36 percent. Among children, on the other hand, LAIV has been more effective than inactivated vaccine. This difference is likely due to adults' pre-existing cross-reactive antibody against the seasonal strains of influenza in the serum, which diminishes replication of the vaccine virus. However, since no one has the antibody against the 2009 H1N1 virus, LAIV is expected to be at least as effective as inactivated vaccine against H1N1 influenza in adults this year.
2010 OMA Wall Calendars Now Available
Extra copies are available for just $4. Call (503) 619-8000 for details.
State Emergency Registry of Volunteers Now Recruiting Physicians
The State Emergency Registry of Volunteers in Oregon, or SERV-OR, is currently recruiting physicians to join its network of volunteers and put their skills to use in emergency situations. SERV-OR is a secure web-based registry that allows physicians and other health professionals to register as volunteers for their local Medical Reserve Corps and the State Managed Volunteer Pool.
The Medical Reserve Corps is a national program under the U.S. Surgeon General's Office that utilizes medical, public health and other volunteers to improve the health and safety of our communities by improving health literacy, eliminating health disparities, increasing disease prevention, and improving public health preparedness, especially in underserved communities. There are currently 13 MRC units in Oregon with nearly 900 volunteers. As of mid-November, nine of these MRC units had been activated or were planning to activate their volunteers in response to the H1N1 influenza pandemic. Volunteers may help a local MRC unit provide vaccinations at a mass vaccination clinic or help staff an access to care triage hotline, for example. State Managed Volunteers have the additional opportunity to apply their skills in a statewide or national emergency.
To learn more about the Medical Reserve Corps and to locate the nearest MRC, visit A short multimedia presentation on the SERV-OR website provides details on the program and how to get involved. Visit or contact Akiko Berkman at or (503) 593-6228 for more information.
OMA Provides ReviewsofUnitedHealthcare and PacificSource Contracts
Request a copy today!
On behalf of its members, the OMA has completed reviews of both UnitedHealthcare's Medical Group Contract and PacificSource's Participating Provider Service Agreement. These reviews relate to the non-price terms to which physicians and their groups must agree as a condition of participation in these health plans.
The reviews contain general and specific observations regarding the contents of these contracts, including an outline of several sections that may need further clarification. However, the OMA's reviews do not make any recommendations as to whether or not physicians should participate in these contracts.
These reviews are only available to members upon request. To request a copy of each review, please contact Christi Donaugh at or (503) 619-8000.
OMA Gathering Donationsfor Portlanders in Need
During the month of December, staff at OMA headquarters is accepting donations in support of the Portland Police Bureau Sunshine Division, which provides emergency food and clothing relief year-round to Portland families and individuals in need. This year, we invite OMA members, their families and others to join us in this effort by contributing non-perishable food items; we will ensure they are delivered appropriately. Donations may be brought to OMA headquarters at 11740 SW 68th Parkway, Suite 100, Portland. In these challenging economic times, every donation means so much. Thanks to those who have already made donations.
OMB Administrative Rule Change - CME Requirements
The Oregon Medical Board has recently made changes to the administrative rules regarding continuing medical education that will be applicable in the next renewal cycle (2012/2013). The recently adopted rules also institute a penalty system for failure to comply with CME requirements.
The administrative rule change requires licensees to complete 60 hours of CME per two years relevant to the licensee's current medical practice. Failure to comply may result in an audit. If a physician is audited and is CME deficient, he or she has 90 days to come into compliance with CME requirements and will be fined $250. If after 90 days the physician fails to comply, he or she will be fined $1,000, and after 180 days of non-compliance, the physician's license will be suspended for at least 90 days.
Licensees with Emeritus status, as well as those in residency training or licensees deployed outside Oregon for 90 days or more while serving in the military are exempt for the initial reporting period. For more information on the OMB administrative rule change, contact Annabel Lucas at or (503) 619-8000.
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Order 2010 Coding Publications Now - Member Discounts Available
2010 Coding books and other AMA publications are available to OMA members and their staff at discounted prices. Visit and scroll to the bottom of the page for an order form. For further information, contact Christi Donaugh at or (503) 619-8000.
2010 Loss Prevention Schedule Now Available Online
Visit for course details and online registration.
MEDICARE UPDATE:
The 2010 Medicare Physician Payment Final Rule
Reprinted with permission from the AMA
The 2010 Medicare physician payment final rule was released on Oct. 30 and at press time was scheduled to be published in the Federal Register on Nov. 25. Key provisions are outlined below.
2010 Update: The rule establishes a 2010 payment update of -21.2 percent. A cut of this magnitude is without precedent and is due largely to the approach Congress has used in a series of short-term band-aid approaches used to stop previous cuts. The AMA is aggressively pursuing sustainable growth rate repeal this year as part of health system reform to eliminate the threat of steep pay cuts once and for all. The rule also indicates that the 2010 Medicare Economic Index is 1.2 percent.
SGR Drugs: The major highlight of the rule is that it finalizes the Centers for Medicare and Medicaid Services' proposal to retroactively remove drugs from SGR calculations, restoring $122 billion to funding for physician services over 10 years. The AMA has long called for this action and appreciates the Obama administration's change in policy.
Practice Expense: While attention has focused on new practice expense proposals for 2010, this year will also see the completion of a transition to a revised methodology that continues to produce significant redistributions. In the final rule, CMS announced that 2010 will be the first of a four-year transition to two new practice expense revisions:
CMS will utilize the results of the Physician Practice Information Survey, sponsored by the AMA and 72 specialty societies and health professional organizations (more information at
CMS will adopt an assumption that diagnostic imaging equipment such as CT and MRI are in use 90 percent of the time an office is open instead of 50 percent (the proposed rule would have applied this assumption to therapeutic equipment as well, but the final rule does not)
The combined impacts of completing the transition to the revised methodology, starting the transition to the new values based on the survey, and the higher equipment use assumption produce significant 2010 practice expense cuts for some specialties, including five percent for cardiology and 10 percent for nuclear medicine. Impacts during the final three years of the new transition will be more modest than in 2010 because the methodological change already underway will have been completed.
Consultations: CMS has finalized its proposal to eliminate Medicare payment for consultations and use the money from these services to increase payments for visits, including visits bundled into global surgical services. The AMA had expressed strong concern to CMS about finalizing its proposal this month and implementing it in January because there is not enough time to educate physicians on such a major change in coding practice. Nonetheless, CMS decided to finalize the policy as proposed and move forward in January.
Misvalued Codes: CMS has accepted the AMA/Specialty Society RVS Update Committee recommendations for nearly 200 physician services identified as potentially misvalued. Savings from these RUC recommendations will be redistributed within the payment schedule through a positive adjustment to the 2010 conversion factor. CMS also accepted 98 percent of the RUC recommendations for new and revised CPT® 2010 codes.
E-Prescribing: The AMA had expressed strong concerns to CMS about the reporting burden for the e-prescribing incentive program. In response, for 2010 physicians will only have to report the e-prescribing code 25 times instead of reporting it for 50 percent of visits in order to qualify for the incentive payment. In addition, in 2010 there will only be one code instead of three, eligible services will be expanded to include home and nursing home visits, and there will be a reporting option for qualified group practices. Also, physicians will be able to choose whether to submit e-prescribing data through claims or a qualified registry or electronic health record product.