- Published: 23 May 2011
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Effective August 27, 2013
Prescribers Who Fall Under an ISTOP Exception Must Document the Specific Exception in Patient’s Medical Chart
The ISTOP law which took effect Tuesday, August 27 requires most practitioners to consult the Prescription Monitoring Program (PMP) Registry prior to prescribing a schedule II, III or IV controlled substance and requires the practitioner to document such consultation in the patient’s medical chart. The ISTOP law includes a number of exceptions to the PMP consultation requirement. If a practitioner falls under one of these exceptions when prescribing a schedule II-IV prescription, the ISTOP regulations still require that the practitioner document in the patient’s medical chart the reason such consultation was not performed. Such documentation shall include the specific exception as outlined in the regulations.
To assist practitioners in ensuring that they are properly documenting exceptions, below is the list of exceptions in the ISTOP regulations that should be noted by the practitioner:
Ten ISTOP Exceptions to the Duty to Consult the PMP Requirement to be Noted in the Patient’s Medical Record:
2. A Practitioner Dispensing Methadone to an addict awaiting admission to a maintenance program;
3. A Practitioner Administering a Controlled Substance;
4. A Practitioner Prescribing or Ordering a Controlled Substance for a Patient of an Institutional Dispenser (defined as a hospital, veterinary hospital, clinic, dispensary, maternity home, nursing home, mental hospital or similar facility approved and certified by NYSDOH as authorized to obtain controlled substances by distribution and to dispense and administer such substances pursuant to the order of a practitioner) for use on the premises of or an emergency transfer from the institutional dispenser;
5. A Practitioner Prescribing a Controlled Substance in the Emergency Department of a general hospital when the quantity does not exceed a Five-Day Supply;
6. A Practitioner Prescribing a Controlled Substance to a Patient under the care of Hospice;
7. A Practitioner when:
a) It is not reasonably possible for the practitioner to access the PMP in a timely manner;
b) No other practitioner or authorized designee is reasonably available; and
c) The quantity of controlled substance prescribed does not exceed a five-day supply.
8. A Practitioner acting in circumstances under which consultation of the PMP would result in a patient's inability to obtain a prescription in a timely manner, thereby adversely impacting the medical condition of such patient, provided that the quantity of the controlled substance does not exceed a five-day supply;
9. A situation where the PMP is not operational or where it cannot be accessed by the practitioner due to a temporary technological or electrical failure; or
10. A practitioner to whom the Commissioner of Health has granted a waiver from the requirement to consult the PMP. A waiver could be issued by the Commissioner based upon a showing by a practitioner that his or her ability to consult the PMP is unduly burdened by:
a) Technological limitations that are not reasonably within the control of the practitioner; or
b) Other exceptional circumstance demonstrated by the practitioner.
Prescription Monitoring Program Reaches 1 Million Searches DOH Announces A Paperless HCS Account
The New York State Department of Health’s Bureau of Narcotics Enforcement announces that 24 days after the implementation of “duty to consult” provision under the ISTOP law, there has been one million searches of the Prescription Monitoring Program (PMP).
Physician activity for establishing a Health Commerce System account remains high and DOH this week announced a new paperless HCS User Account process for requesting user HCS accounts. The online user form requires a New York State Department of Motor Vehicles (NYS DMV) driver license or NYS DMV non-driver photo ID to register for an account.
The new process has two steps:
1. Register for a user account.
2. Enroll your account on the HCS.
The New York State of Health, New York’s Health Insurance Exchange, opened its customer service center to answer questions from consumers and small businesses regarding purchasing health insurance coverage through the Exchange. New York State of Health is an organized marketplace designed to help people shop for and enroll in health insurance coverage. Individuals, families and small businesses will be able to use the Health Plan Marketplace to compare insurance options, calculate costs and select coverage online, in-person, over the phone or by mail. Through the Health Plan Marketplace, individuals can check their eligibility for health care programs like Medicaid and sign up for these programs if they are eligible. Financial assistance is available to qualifying applicants to help them afford insurance purchased through the Marketplace.
Insurance coverage can be purchased through New York State of Health beginning in October 1, 2013 with coverage becoming effective starting January 1, 2014.
Several health insurance companies indicated they will offer coverage through the Exchange across the State of New York. To view which companies will be offering individual and small business coverage in your county, view this link http://www.nystateofhealth.ny.gov/PlansMap.
What Do Individual EPs need to do?
Individual eligible professionals (EPs) can submit data through the traditional PQRS methods (claims, registry and EHR) to avoid the 2015 payment adjustment and potentially earn a 2013 incentive payment of 0.5%. Alternatively, to avoid the payment adjustment only, EPs can request that CMS calculate their quality data from administrative claims. EPs must register for the CMS-calculated administrative claims option by October 15, 2013. To register for the CMS-calculated administrative claims option, EPs should use the instructions and information available in the Quick Reference Guide for Individual EPs.
What Do Group Practices (with 2-99 EPs) Need To Do?
Group practices with 2-99 EPs can register to report under the PQRS Group Practice Reporting Option (GPRO) to avoid the 2015 PQRS payment adjustment and potentially earn a 2013 PQRS incentive payment of 0.5%. However, it is not required that they register under the GPRO if the preference is for each EP to report PQRS as an individual. Reporting options for group practices include the web-interface GPRO and registry. The reporting option available to the group will depend on the group size, so group practices should determine how many EPs they have billing Medicare under their tax identification number. Alternatively, to avoid payment adjustments only, groups can request that CMS calculate their quality data from administrative claims. Group practices must register and select their reporting method by October 15, 2013. Please note: Groups with less than 100 EPs are not subject to the value modifier (VM) for 2015. To register as a group practice and select a reporting method, group practices should use the instructions and information available in the Quick Reference Guide for Group Practices.
Physician Groups of 100 or More: 2 Weeks Left to Register for PV- PQRS to Avoid a -1% Payment Adjustment
The Physician Value-Physician Quality Reporting System (PV-PQRS) Registration System is open for representatives of group practices to select their group’s PQRS reporting mechanism for CY 2013, and for groups with 100 or more eligible professionals (EPs), to elect quality tiering to calculate the Value Modifier for CY 2015. Additionally, individual EPs will be able to select the CMS-calculated administrative claims reporting mechanism in CY 2013 in order to avoid the PQRS negative payment adjustment in CY 2015.
The PV-PQRS Registration System will close on October 15, 2013. The PV-PQRS Registration System can be accessed at https://portal.cms.gov using a valid IACS User ID and password. For additional information regarding registration and obtaining or modifying an IACS account please see the Quick Reference Guide on the Self Nomination/Registration web page.
Implementation of I-STOP Law
The “duty to consult” the prescription monitoring program will become effective on August 27, 2013. The I-STOP law requires that the existing prescription monitoring program be enhanced to include information about dispensed controlled substances reported by pharmacies on a “real time” bases (to be defined in regulation). Beginning August 27, 2013 prescribers will have a duty to consult the database prior to prescribing Schedule, II, III and IV controlled substances. To access the prescription monitoring program physicians will need to obtain a Health Commerce System (HCS) account.
New York ACEP was able to get one of the few exemptions from the mandatory consultation of the prescription monitoring program requirement in the bill for five-day prescriptions written in emergency departments.
The I-Stop law also mandates the electronic submission of most prescriptions by December 31, 2014.
The law provides for the establishment of the DOH Work Group on Prescription Pain Medication Awareness that will make recommendations to the Commissioner of Health on continuing medical education on pain management issues for prescribers and pharmacists; the implementation of the I-STOP provisions and the education of the public in regards to controlled substances.
Medicare Pay Cut to Kick in April 1 under Federal Budget Sequester
The Centers for Medicare & Medicaid confirmed in a recent announcement that the two percent across-the-board cut to Medicare physician payments mandated by the federal budget sequester will begin April 1.
Physicians will see the payment reduction applied to their fee-for-service claims with a date of service of April 1 or later. The two percent cut will apply to the payment amount after it has been adjusted for beneficiary coinsurance, deductibles and any applicable Medicare secondary payments. The allowed charge amounts remain unchanged.
DFS Prompt Payment Hotline for Physician Complaints
Did you know that the New York State Department of Financial Services (DFS) maintains a “Prompt Payment Hotline” for physicians to file complaints about insurance companies when they inappropriately delay or deny payment of claims? The phone number is 1-800-358-9260. There is also an on-line portal for physicians to use to file a complaint: https://myportal.dfs.ny.gov/home.
The New York State Department of Financial Services has imposed tens of millions in dollars in fines on insurance companies over the last several years for failure to pay claims promptly, as well as a host of other violations such as failing to inform consumers of their statutory rights to be able to appeal claims and inappropriately calculating patient deductibles.
Senator Schumer Seeking Change in Medicare Observation Rule
New York Senator Chuck Schumer plans to co-sponsor legislation to stop Medicare from denying payments to people hospitalized under 'observation' status. Referring to a rule which draws a distinction between the term 'admitted' and being classified as an 'observation' patient, Schumer said, "Frankly, it's unconscionable that so many elderly people are being denied Medicare coverage for a technical loophole that Medicare is pushing." He held a news conference on February 20 to say "that he and Senator Sherrod Brown of Ohio will file the Improving Access to Medicare Coverage Act of 2013," designed to "count observation stays toward the three-day minimum."
Governor Cuomo and the Legislature Reach Final Agreement on a State Budget
Governor Andrew Cuomo and Legislative Leaders have reached an agreement on a FY 2013-14 State Budget. The Budget totals approximately $135 billion plus federal Hurricane Sandy and Affordable Care Act aid. It closes a $1.3 billion budget gap for the upcoming fiscal year with spending held to under the 2% cap along with cuts to a number of areas, most notably health and mental hygiene.
The agreement is a 2-year budget framework which includes tax cuts for middle-income families, an extension of the “millionaire’s tax” on high earners, an economic development package worth approximately $300 million, a phased in minimum wage increase reaching $9 by 2016, increased funding to education and a pension stabilization plan.
Negotiations continue on the decriminalization of possession of small amount of marijuana but some changes are included in the final budget on the SAFE ACT gun law to suspend the ban on purchasing more than seven but less than ten-round ammunition magazines, which was scheduled to take effect on April 15.
The Senate was in Albany on March 24 to pass four budget bills that were in print last week and had aged the necessary three days. All budget bills are expected to be passed by the Legislature before the week’s end.
Below is a summary of the final budget as it relates to physician priorities and other areas of interest.
Excess Medical Malpractice Pool (MMIP)
The Governor’s Budget proposal to limit the eligibility for Excess Medical Malpractice Coverage was rejected and $12.7 million in funds were restored to the program, for a total of $127.4 million.
The final Budget provides that eligibility for the program is limited to physicians and dentists who participated for the coverage period ending June 30, 2013.
For the coverage period beginning on July 1, 2013, the Superintendent of the Department of Financial Services (DFS) and the Commissioner of Health must purchase up to 1000 more policies than were purchased for the coverage period ending June 30, 2013.
A general hospital may certify additional eligible physicians or dentists in a number equal to such general hospital’s proportional share of the total number of physicians and dentists for whom coverage was purchased with funds available in the pool as of June 30, 2013 as applied to the greater of: 1000; or the difference between the number of eligible physicians or dentists for whom a policy was purchased for the coverage period ending June 30, 2013 and the number who have applied for excess coverage beginning July 1, 2013.
The bill authorizes the Superintendent of DFS to enter into a contract or contracts, without a competitive bid or request for proposal, to administer the Hospital Excess Liability Pool.
Article 30, Emergency Medical Services (EMS)
The final Budget rejects, in its entirety, the Executive Budget proposal to significantly restructure and consolidate the State’s EMS program.
Nurse Practitioners (NPs)
Despite the support from the Governor and Assembly in their budget proposals, the final State Budget rejects the proposal to remove the collaborative agreement requirement for NPs.
Physician Assistants (PAs)
The final Budget includes a change in the ratio of the number of physician assistants that a physician is permitted to supervise from “no more than two” to “no more than four” in his or her private practice. However, a physician employed by or rendering services to the Department of Corrections and Community Supervision may supervise no more than six PAs (current law is four PAs).
The final Budget rejects the Executive Budget proposal to authorize and regulate retail (limited services) clinics.
The final Budget retains provisions of the Executive Budget proposal to require radiologic technologists licensed in New York who are either licensed or seeking licensure in another state to immediately report to DOH any out-of-state criminal convictions or disciplinary actions.
Doctors Across New York
The final Budget rejects the Executive Budget proposal to consolidate 89 “public health” programs into six categories. Also it reduces the proposed cut for these programs from 10% (as proposed by the Governor) to approximately 5%. Programs include Doctors Across New York and Area Health Education Center funding.
Expedited Partner Therapy (EPT)
The final Budget includes the Governor’s proposal to remove the expiration date of January 1, 2014 in the state law which permits physicians to use EPT for Chlamydia. In doing so, this law is made permanent.
Office of Medicaid Inspector General
The final Budget includes the following new provisions related to the Office of the Medicaid Inspector General (OMIG):
- Increases from 10-20%, the amount of Medicaid recovery savings to be shared with applicable social services districts through the social services district demonstration programs;
- Requires OMIG to provide a quarterly briefing to the Legislature on its activities;
- Requires OMIG to meet quarterly with local social services districts to discuss ongoing cooperative efforts, potential additional collaborations and any issues of concern with respect to the prevention and detection of fraud and abuse in the Medicaid program;
- Requires OMIG to request submission of social services districts annual budget and audit work plans for planning and executing the county demonstration and for creation of the OMIG’s annual work plan;
- Requires OMIG to develop materials on its audit standards and criteria for identifying fraud or waste, for use by social services districts engaged with the OMIG demonstration programs and other collaborative efforts; and
- Inclusion of a narrative in the NYSDOH annual report that summarizes the Department’s activities to mitigate fraud, waste and abuse during the prior year.
Volume 13:01-15 (January 2013)
The Joint Commission is putting hospital leaders on notice that boarding in the emergency department requires a hospital-wide solution
In performance standards that went into effect January 1, the Joint Commission is requiring hospitals to set specific goals to improve patient flow, which include ensuring the availability of patient beds and maintaining proper throughput in laboratories, operating rooms, inpatient units, telemetry, radiology, and the postanesthesia care unit. The Joint Commission is also calling on hospitals to ensure the efficiency of nonclinical services such as housekeeping and transportation and to maintain access to case management and social work.The standards specifically name the medical staff, the chief executive officer, and other senior hospital managers as having a responsibility to take action when patient flow goals are not met.
The updated patient flow standards also include some brand new elements, though the new requirements won’t go into effect until January 1, 2014. Under the new rules, hospitals must measure and set goals for curbing the boarding of patients in the ED. The new requirement defines boarding as the "practice of holding patients in the emergency department or another temporary location after the decision to admit or transfer has been made." Boarding goals should be based on patient acuity and best practice, the Joint Commission wrote, but it recommended that boarding times should not exceed 4 hours.
Hospitals won’t be scored on the 4-hour guideline during their surveys. The expectation is that hospitals will set their own time limits for boarding and they will be scored based on their own goals. Joint Commission surveyors, however, will question hospital leaders about what conditions require boarding times beyond 4 hours.
The Joint Commission also set new rules for boarding related to behavioral health emergencies. A new requirement, which also takes effect on January 1, 2014, calls on hospital leaders to work with behavioral health providers in the community on better care coordination for these patients.
Additionally, the Joint Commission released a new requirement that hospitals provide patients who are awaiting care for emotional illness or substance abuse with a safe, monitored location. Hospitals are also required to provide training to clinical and nonclinical staff on caring for these patients, including medication protocols and de-escalation techniques. These requirements took effect on January 1, 2013.
Doctors Across New York (DANY) Physician Practice Support and Physician Loan Repayment Programs Cycle III applications are now available
Physician Practice Support provides up to $100,000 in funding over a two year period to applicants who can identify a licensed physician that has completed training and will commit to a two year service obligation in an underserved region within New York State.
Physician Loan Repayment provides up to $150,000 in funding over a five year period for physicians who commit to a five year service obligation in an underserved region.
Application materials can be found on the Department of Health website at: www.health.ny.gov/professionals/doctors/graduate_medical_education/doctors_across_ny/
Office of Primary Care
NYS Department of Health
Corning Tower, Room 1695
Albany, New York 12247
(518) 473-3513 or 473-7019
Audit Spurs Improvements At Health Department's Bureau of Narcotic Enforcement
DiNapoli Calls for More Consistent Statewide Approach
The State Health Department's Bureau of Narcotic Enforcement tightened processes for combating abuse of prescriptions for controlled substances during an audit by the State Comptroller's office that ultimately found hundreds of thousands of prescriptions that may have been abused, poor controls over unused prescription forms and significant variations in bureau drug investigation practices across the state.
"The abuse of prescription medications has reached epidemic proportions and the costs to society are enormous," DiNapoli said. "Attorney General Schneiderman deserves credit for spearheading a statewide electronic prescription drug database, I-STOP, that will help to crack down on prescription drug abuse. I commend Governor Cuomo and his team for introducing legislation and making leadership changes that are moving the Bureau of Narcotic Enforcement in a positive direction. The bureau needs to aggressively pursue new ways to prevent, detect, investigate and prosecute illegal prescription activities."
The bureau is the state Department of Health's (DOH) lead office charged with combating the illegal use and trafficking of controlled substances in New York.
DiNapoli's auditors examined 28.5 million prescriptions dispensed over a 15-month period and found more than 325,000 prescriptions for controlled substances, filled more than 565,000 times, contained errors or inconsistencies in critical information.
Zolpidem (a drug sometimes marketed as Ambien), Oxycodone (a pain medication commonly marketed as OxyContin), and Hydrocodone (a pain medication sometimes marketed as Vicodin) accounted for nearly half of the drugs acquired with these prescriptions.
- More than 130,000 instances where data showed that the prescriptions used to obtain controlled substances contained an invalid Drug Enforcement Administration registration number that did not match the prescriber;
- Almost 180,000 instances where prescription numbers appeared more than once in the data, having been filled at different locations or with inconsistent information about the prescriber or the drug dispensed;
- More than 90,000 prescriptions were refilled more than 157,000 times beyond their authorized refill quantities. This included almost 12,000 prescriptions for Schedule II controlled substances that were refilled more than 17,000 times even though these types of medications are not allowed to be refilled at all because they are the most dangerous and highly addictive drugs allowed to be prescribed in New York; and
- 135 instances where prescriptions had been written by practitioners whose licenses had been revoked, suspended, surrendered or otherwise inactivated.
DOH contends that many of these questionable prescriptions were likely attributable to data entry errors. The bureau was able to identify what it believes are the likely causes of about 50,000 discrepancies.
Auditors also found the bureau's five regional offices did not have a consistent approach for what they investigated, which resulted in inconsistent outcomes. For example, the Syracuse office accounted for half of the bureau's completed cases that resulted in criminal charges, while the Buffalo office produced less than 10 percent. In contrast, the Buffalo and Rochester offices together generated about 80 percent of the cases that resulted in civil penalties and administrative warnings, while the New York City office had none.
Auditors determined that the bureau relies heavily on external tips and sources as the starting point for the majority of its cases and much less on data mining techniques that can be more effective in identifying suspicious activity. In response to the audit, the new director of the bureau has recently implemented new data mining strategies and officials say they plan to assign additional resources to conduct these analytic techniques. The bureau's full response is included in the audit.
Additionally, auditors found that returned and unused prescription forms were not always properly secured and accounted for. Auditors examined a box that had not been properly inventoried and kept inside a locked cabinet as required and found 2,034 prescriptions that had not been logged in, including 1,500 pieces of blank electronic medical record paper which could easily be made into counterfeit forms. Over 4,000 returned forms maintained by a DOH contractor that were supposedly destroyed showed up in the bureau's records as being used to obtain controlled substances.
Auditors recommended the bureau:
- Increase its use of advanced analytical techniques to pinpoint possible cases of drug diversion;
- Pursue crimes with a consistent and coordinated approach across the state; and
- Secure and account for unused prescription forms.
Albany Phone: (518) 474-4015 Fax: (518) 473-8940
NYC Phone: (212) 681-4840 Fax: (212) 681-7677
Follow us on Twitter: @NYSComptroller
Medicaid to Cease Support of the OMNI 3750 POS Card Swipe Terminals on March 31, 2013
Medicaid is discontinuing support of the OMNI 3750 Point of Service (POS) device effective March 31, 2013. Providers who do not participate in the Medicaid Cardswipe Program and who currently use the Omni 3750 POS Device to verify Medicaid eligibility or request Dispensing Validation System (DVS) prior approval must make plans to switch to one of the following real-time methods prior to the March 31, 2013 date.
- Electronic Provider Assisted Claim Entry System (ePACES)
- eMedNY Simple Object Access Protocol (SOAP)*
- Several large clearinghouses and service bureaus support real-time connections to eMedNY (If you require DVS, verify DVS availability with the clearinghouse prior to contracting.)
*Does not support DVS transactions
Providers should visit www.emedny.org to determine which alternate method best meets their needs.
All providers participating in the Cardswipe Program who have 3750 terminals will soon receive a separate letter from the New York State Office of the Medicaid Inspector General on the status of their involvement in the Cardswipe Program.
Instructions for Beneficiaries Enrolled in Medicare Managed Care Plans
Billing guidelines previously published in the November 2009 and January 2010 Medicaid Update instructed providers to use Claim Filing Indicator Code 16 to bill Patient Responsibility amounts to Medicaid following payment from a Medicare Advantage Plan.
Since these instructions were issued, claims have been submitted to Medicaid using Claim Filing Indicator Code 16 for Medicaid beneficiaries who were not enrolled in a Medicare Advantage plan.
Therefore, effective December 1, 2012, all claims indicating Medicare Advantage plan coverage (Claim Filing Indicator Code 16), must have an active Medicare Advantage Plan in the eMedNY system for the date of service, or the claim will be denied. The denial message will read “Pyr 16 Invalid- Client Not Enrol In MCARE Advant.”
If a claim is denied, non-pharmacy providers must rebill the claim eliminating Indicator Code 16. Pharmacy providers must rebill their NCPDP D.O claims without the indicator code that denotes Medicare Advantage plan coverage.
Questions? Please contact the eMedNY Call Center at (800) 343-9000.
2012 e-news archives
Changes In Medicaid Billing for Vaccine Administration
There are changes in billing for Vaccine Administration for dates of services on and after January 1, 2013.
Attention Practitioner Providers: additional billing information for vaccine administrations
As a result of NCCI editing, claims may be denied Edit 00715 (Procedure conflicts with prior service) when an office visit (E&M and preventative medicine codes) and a vaccine administration service is billed on the same day of service.
NCCI will allow payment for both services when a separately identifiable office visit was performed that meets a higher complexity level of care than a service represented by CPT code 99211.
For payment to be made for both services, the office visit must be billed with Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Providers must maintain documentation in the medical record to support use of an appropriate modifier.
Questions: Medicaid billing assistance: CSC, 1-800-343-9000.
2011 e-news archives
2010 e-news archives