THE OFFICIAL MAGAZINE OF THE MICHIGAN STATE MEDICAL SOCIETY » VOL. 118 / NO. 2
March / April 2019
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FEATURES & CONTENTS March / April 2019
08
It’s Time for Kindergarten Roundup: Make Sure Your Pediatric Patients are Up-to-Date on Vaccines STEFANIE COLE, BSN, RN, MPH
10
WHEN can you Google search a job applicant? That is the question. BY JODI SCHAFER, SPHR, SHRM-SCP
12
New Controlled Substance Prescribing Rules in Effect BY MICHIGAN STATE MEDICAL SOCIETY
22
Survey: Doctors Conflicted but Patients Still Top Concern BY BILL FLEMING
COLUMNS 04 President's Perspective
BETTY S. CHU, MD, MBA
06 Ask Our Lawyer
DANIEL J. SCHULTE, MSMS LEGAL COUNSEL
FEATURE
Health Can't Wait BY NICK DELEEUW FOR THE MICHIGAN STATE MEDICAL SOCIETY
Patients and physicians across the state are highlighting the urgent need for a patient-centered approach in health care that puts the needs of patients above bigger profits for insurers. Read more about it on page 16.
STAY CONNECTED!
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MICHIGAN MEDICINE® VOL. 118 / NO. 2 Chief Executive Officer JULIE L. NOVAK Managing Editor KEVIN MCFATRIDGE KMcFatridge@msms.org Marketing & Sales Manager TRISHA KEAST TKeast@msms.org Publication Design STACIA LOVE, REZÜBERANT! INC. rezuberant.com Printing FORESIGHT GROUP staceyt@foresightgroup.net Publication Office Michigan Medicine® 120 West Saginaw Street East Lansing, MI 48823 517-337-1351 www.msms.org All communications on articles, news, exchanges and advertising should be sent to above address, ATT: Trisha Keast. Postmaster: Address Changes Michigan Medicine® Trisha Keast 120 West Saginaw Street East Lansing, MI 48823
Michigan Medicine®, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan. The MSMS Committee on Publications is the editorial board of Michigan Medicine® and advises the editors in the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors. Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine® reserves the right to accept or reject advertising copy. Products and services advertised in Michigan Medicine® are neither endorsed nor warranteed by MSMS, with the exception of a few. Michigan Medicine® (ISSN 0026-2293) is the official magazine of the Michigan State Medical Society, published under the direction of the Publications Committee. In 2019 it is published in January/February, March/April, May/ June, July/August, September/October and November/December. Periodical postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110. Single copies, $10. Printed in USA. ©2019 Michigan State Medical Society
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perspective
By Betty S. Chu, MD, MBA, Michigan State Medical Society President
®
Health can’t wait. It’s a reality that physicians understand and patients experience. Tragically, insurance company bureaucracy too often stands between patients and the medicine, treatment, or testing their physicians believe they need. Prior authorization, step therapy, and fail first requirements hamstring treatment, drive up prescription non-adherence and lead to diminished health. They also cost lives.
In this edition of Michigan Medicine®, you’ll hear from Michigan patients, providers, and practice staff about the devastating impact prior authorization has on the state’s patient community.
BETTY S. CHU, MD, MBA MSMS PRESIDENT
You’ll learn about the very personal, very human toll of that kind of red tape and regulation. You’ll also learn about the latest studies and numbers, painting a fuller picture of the national devastation of these types of payer practices. The good news is patients aren’t in this alone. They’ve got champions, and we’re ready to fight. In this issue you’ll learn about a brand new coalition that’s been created in Michigan to defend patients against these costly, onerous, and dangerous payer practices. The initiative – titled Health Can’t Wait – is bringing together the state’s leading physician and health care associations and organizations to speak with a single, clear voice and tell policymakers it’s time to put Michigan patients first.
Betty S. Chu, MD, MBA MSMS President
JANUARY MARCH / FEBRUARY / APRIL 2019 |
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ASK OUR LAWYER
Auto-Owners v. Compass Healthcare Decision Makes Collecting Full Fee From No Fault Insurers More Difficult By Daniel J. Schulte, JD, Kerr Russell
: Q
I heard that our Court of Appeals recently decided a case that makes it more difficult for me to collect my full fee from a no-fault insurer. I routinely treat patients that have been injured in auto
accidents. Collecting my full fee on a timely basis has always been a challenge. Can you please explain what was decided in this case and what it means for physicians owed money for their services provided to auto accident victims?
F
irst, a reminder of what our Supreme Court decided in 2017 in Covenant Medical Center v. State Farm would be helpful. In Covenant the Court held that healthcare providers have no right under the No Fault Act to sue their patient’s no fault insurer for payment of their bills. This was a dramatic departure from decades of Court of Appeals case law holding that healthcare providers may sue a no-fault insurer to recover their patient’s benefits for payment of their bills. However, the Court was careful to point in Covenant that its decision did not affect either: a health care provider’s recourse directly against patients for payment; or a patient’s ability to assign his/her right to past or presently due no-fault benefits to a health care provider.
Following Covenant, a health care provider collecting the balance of a bill from the patient was thought to be a possibility. That possibility was severally limited by the most recent Court of Appeals decision on this subject, the case you refer to, AutoOwners v. Compass Healthcare et. al. That case involved a patient with injuries suffered in an auto accident. The physician’s charges totaled $1,859.00. The patient’s no fault insurer deemed $1,076.14 to be the reasonable charge for the physician’s services and paid this amount. The physician sent several
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collection notices to the patient for the $782.86 balance. Ultimately, the no fault insurer sued seeking a declaratory ruling that the physician could not obtain payment of the balance bill from the patient. The Court of Appeals in the Auto-Owners v. Compass Healthcare et. al. case sided with the no-fault insurer, holding that the physician may not collect any amount in excess of the “reasonable” fee determined by the no-fault insurer and that any dispute regarding what constitutes a reasonable fee is between the physician and the patient (not the no-fault insurer). The Court also held that a physician’s attempts to collect a balance bill from a patient (as opposed to disputing a no-fault insurer’s determination of reasonableness) could subject the physician to liability under Michigan’s Regulation of Collection Practices Act. The physician’s argument
that he was entitled to payment of the balance of his bill based on a contract for payment between him and the patient was rejected by the Court which made clear that the physician was entitled to no amount in excess of what the no-fault insurer deemed to be reasonable. Following the Court of Appeals decision in Auto-Owners v. Compass Healthcare et. al. health care providers with bills that have been reduced to a reasonable amount by no-fault insurers must either accept what has been paid or sue their patients to dispute what is a reasonable amount. The only exception would be for the physician to obtain an assignment of benefits from the patient. An assignment would allow the physician to dispute the reasonableness of the charges directly with the no-fault insurer (instead of having
to sue a patient). As has been stated in this column previously, the best practice would be to have the patient sign an assignment of benefits form each time services are provided covering fees for the services then being provided and past services. Assignments of future benefits are prohibited by MCL 500.3143. DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL IS A MEMBER AND MANAGING PARTNER OF KERR RUSSELL
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MDHHS UPDATE
It’s Time for Kindergarten Roundup: Make Sure Your Pediatric Patients Are Up-to-Date on Vaccines By Stefanie Cole, BSN, RN, MPH, Immunization Nurse Educator, Michigan Department of Health and Human Services Division of Immunization
It’s finally springtime! And springtime means it’s time for kindergarten roundup. Children are perfect vectors for disease, especially in close group settings such as the classroom, cafeteria, and playground. If you see pediatric patients between 4 and 6 years of age, make sure you assess their immunization record at every visit to see which vaccines they need.
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confirmed cases of measles in Michigan in 2018, the most cases since 1994 when 26 cases were reported.
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T
o best protect children from vaccine-preventable diseases, healthcare providers should vaccinate their patients according to the Advisory Committee on Immunization Practices’ (ACIP) recommended immunization schedules.1 Michigan administrative rules require all kindergarteners and 4-6-year-old transfer students to have appropriate documentation of vaccines protecting against diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, hepatitis B, and varicella. For some of these diseases, appropriate documentation of immunity from the disease is acceptable in lieu of vaccination. For the 2017-18 school year, Michigan’s kindergarteners had decent coverage levels of select vaccines (95.3% for 4 or 5 doses of DTaP, 95.0% for 2 doses of MMR, 94.7% for 2 doses of varicella). What’s concerning, though, is that Michigan’s
kindergarten vaccine exemption rate was 10th highest in the country at 4.2%, an increase of 0.5% from the previous year.2 By vaccinating children according to the ACIP schedule, your patients will receive all the vaccines required for school and daycare entry. These vaccines protect against diseases that we still see in Michigan today. While there have been several national measles outbreaks over the past decade, Michigan does not usually see many cases.3 However, in 2018, Michigan had 19 confirmed cases of measles, the most cases we’ve seen since 1994 when 26 cases were reported. Most measles cases in Michigan are associated with unvaccinated international travelers returning to Michigan and spreading the disease to other unvaccinated individuals. These diseases are truly only a plane ride away. It is vital to make sure your pediatric patients are protected against these highly contagious and dangerous diseases to keep them healthy, not just at school but everywhere they go. Even though some ACIP-recommended vaccines are not required for school and daycare entry, they are just as important for children to receive. At a child’s 4-yearold well visit, they should receive DTaP, Polio, MMR, and Varicella. These vaccines are recommended between 4 and 6 years of age but by vaccinating at 4 years, children get that protection earlier. Children should also receive flu vaccine every year, possibly
even two flu vaccines in one season depending on their immunization history. Well visits are also a great time to make sure children are up-to-date for all other vaccine series routinely recommended by ACIP, including Haemophilus influenzae type b (Hib) and pneumococcal conjugate (both up to 5 years of age, i.e., through 59 months), Hepatitis A and B, as well as any other vaccines that may be needed if a child has high-risk medical conditions. In 2017, MDHHS created easy-to-read handouts detailing the school and daycare vaccine requirements and targeting healthcare providers, schools and daycares, and parents. These documents are on the MDHHS website in color and in print-friendly black and white versions.4 As a reminder, healthcare providers should
only provide parents with medical immunization waivers (i.e., true medical contraindications to vaccines) when needed. Refer patients to their local health department for all non-medical waivers for school and daycare. Check the Michigan Care Improvement Registry (MCIR) for every patient at every visit, even sick visits, to determine which vaccines are needed to best protect them. All vaccines administered to persons less than 20 years of age, including flu vaccine, are required to be entered into MCIR within 72 hours of vaccine administration. For more information on MCIR, visit www.mcir.org. By protecting your patients with all ACIP-recommended vaccines, you help young Michiganders stay healthy and ready to learn.
REFERENCES 1 Centers for Disease Control and Prevention (2019). Immunization Schedules. Retrieved from https:// www.cdc.gov/vaccines/schedules/index.html on January 23, 2019. 2 Mellerson JL, Maxwell CB, Knighton CL, Kriss JL, Seither R, Black CL. Vaccination Coverage for Selected Vaccines and Exemption Rates Among Children in Kindergarten – United States, 2017-18 School Year. Morbidity and Mortality Weekly Report 2018;67:1115-1122. DOI: http://dx.doi.org/10.15585/ mmwr.mm6740a3 3 Centers for Disease Control and Prevention (2019). Measles Cases and Outbreaks. Retrieved from https:// www.cdc.gov/measles/cases-outbreaks.html on January 23, 2019. 4 Michigan Department of Health and Human Services (2019). Immunization Waiver Information. Retrieved from http://www.michigan.gov/mdh-
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ASK HUMAN RESOURCES
WHEN can you Google search a job applicant? That is the question. By Jodi Schafer, SPHR, SHRM-SCP, Human Resources Management Services, LLC
: Q
I like to ‘Google’ job applicants before I bring them in for an interview so that I can learn more about them. Most candidates now have a Facebook page and a Twitter and/or Instagram account. Given the current state of our society, I want to make sure I’m not bringing in someone with extreme/highly offensive
views, pictures of inappropriate behavior or someone who posts negative comments about past employers. Since this information is public, I thought it was okay for me to do this, but I’ve recently been questioned on it by another staff member and now I’m not so sure. Can I continue to ‘Google’ applicants before deciding if I want to interview them?
“Can I continue to 'Google’ applicants before deciding if I want to inteview them?” The real question is not ‘can you?’, but instead, ‘WHEN can you?’
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R
unning a quick Google search on a job applicant can be considered a form of a background check. You are pulling public information related to their character and using social media sites, newspaper articles, etc. to inform your opinion about them. However, in doing so, you may also learn about their religious beliefs, their race or ethnic background, their age, their marital or familial status, etc. Making a hiring decision based on these protected classifications is considered discriminatory and is illegal. So, you need to be very careful about WHEN you run an internet search like this.
The first question you are trying to answer when considering a candidate for a job opening is, ‘Are they qualified to do the job?’. Past work experience and documented skills on a resume can give you some indication of fit, but we both know that personality, communication style, expectations around hours/pay/ benefits, etc. also play into whether or not someone will be the right hire for your practice. Many times, these areas are fleshed out in an interview. That interview may be over the phone or face-to-face, but the notes from that interaction provide rational for whether or not someone is still considered a qualified applicant. Once you can defend a decision of qualified vs. unqualified, it becomes less risky to run additional background/ character checks where you could also learn about a person’s protected classification(s).
The short answer to the question is ‘Yes’. You can ‘Google’ an applicant but should do so AFTER you have conducted a screening interview to determine whether or not they are qualified for the job.
Prior to running any sort of character, reference or criminal check, it is important to obtain a signed release from the applicant. This provides another layer of protection for you and informs the applicant that you will be digging into their background further, which may prompt the applicant to share information that had not previously been asked about but will most certainly come to light. The authorization to perform this search should be a standalone document if you are relying on a third party to do this on your behalf. That document needs to have language that complies with the Fair Credit Reporting Act. If you are running the search yourself, especially a Google search, then you can include authorization for this on your employment application, which the applicant completes and signs at the time of their first face-to-face interview.
A sample employment application language may read: “I authorize PRACTICE NAME to investigate my employment history and all statements contained in this application, including records of any former employers and other references or sources concerning me. I authorize all references and sources to provide this information to PRACTICE NAME and release such references and sources from liability for doing so. I waive my right to any written notice of the release of such records that may be required by state or federal law. I understand that due to the nature of the jobs at PRACTICE NAME, an investigative consumer report may be made whereby information is obtained through interviews with various third parties. These inquires may include information as to criminal, credit, driving record, character, general reputation, personal characteristics and mode of living, whichever may be applicable. I understand I have the right to make a written request to PRACTICE NAME, within a reasonable period of time for additional information concerning the nature and scope of any investigation conducted.”
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MARCH / APRIL 2019 |
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HEALTH CARE DELIVERY
New Controlled Substance Prescribing Rules in Effect By Stacey Hettiger, Director Medical and Regulatory Policy, The Michigan State Medical Society
Michigan prescribers and patients have experienced the implementation of several legislative and regulatory actions intended to address Michigan’s opioid crisis over the past year. Most recently, revisions to the Michigan Board of Pharmacy’ Controlled Substance rules were finalized and took effect immediately upon filing with the Office of the Great Seal on January 4, 2019. There were three important changes to the rules; perhaps most notable of which is the identification of exceptions to the “bona fide prescriber-patient relationship” requirement in MCL 333.7303a.
O
n April 2, 2018, the Legislature responded to stakeholder concerns by delaying the effective date of the bona fide relationship provision to March 31, 2019, or upon the promulgation of rules carving out exceptions, whichever was sooner. Because the rule establishing these exceptions was finalized with immediate effect, the requirement of a bona fide prescriber-patient relations prior to prescribing a controlled substance to patients also took effect on January 4, 2019. MSMS and many other health care stakeholders collectively advocated for exceptions that allow prescribers to provide timely, appropriate and non-duplicative care to patients. MSMS Legal Counsel has prepared a Legal Alert detailing the statutory bona fide prescriber-patient relationship requirement, the administrative rule exceptions, and suggested best practices for compliance. The related rule changes follow.
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R 338.3161a Prescribers must be in a “bona fide prescriber-patient relationship” before prescribing a controlled substance listed in schedules 2 to 5. Exceptions allowing a prescriber to prescribe a controlled substance listed in schedules 2 to 5 without first establishing a bona fide prescriber-patient relationship are recognized in the following circumstances: When the prescriber is providing
on-call coverage or cross-coverage for another prescriber who is not available and has established a bona fide prescriber-patient relationship with the patient, as long as the prescriber or an individual licensed under article 15 of the act, reviews the patient’s relevant medical or clinical records, medical history, and any change in medical condition, and provides documentation in the patient’s medical record.
When the prescriber is following or
modifying the orders of a prescriber who has established a bona fide prescriber-patient relationship with a hospital in-patient, hospice patient, or nursing care facility resident and provides documentation in the patient’s medical record. When the prescriber is prescribing for
a patient that has been admitted to a licensed nursing care facility or a hospice and completes the tasks required in subrule (2)(a) and (2)(b) in accordance with the nursing care facility or hospice admitting rules and provides documentation in the patient’s medical record. When the prescriber is prescribing for
a patient, and the tasks required in subrule (2)(a) and (2)(b) are complied with by an individual licensed under article 15 of the Public Health Code and the prescriber provides documentation in the patient’s medical record. When the prescriber is treating a
patient in a medical emergency, as defined in the rule. In addition, prescribers need to be aware of two other important changes as follows:
R 338.3125 Gabapentin has been added to the schedule 5 drug list as a controlled substance. This modification to Michigan Administrative Code Rule 338.3125 establishing gabapentin as a Schedule 5 controlled substance does not prohibit the continued prescription of gabapentin for its current uses. However, physicians prescribing gabapentin must now meet the following requirements: Have a valid Michigan Controlled
Substances License. Have a valid DEA Registration. Be registered with the Michigan
Automated Prescription System (MAPS). Unless an exception applies, have a bona
fide prescriber-patient relationship. Obtain and review the patient’s
MAPS report if prescribing a quantity that exceeds a 3-day supply, unless dispensed and administered to a patient within a hospital or freestanding surgical outpatient facility. Ask the patient about other controlled substances the patient may be using. Record the patient’s response in the patient’s medical record. Additionally, the following Q&A provided by the Michigan Pharmacists Association (MPA) to their members may be of interest:
Q: What are the prescription requirements now that gabapentin is a schedule V? A: Pharmacists shall ensure that gabapentin prescriptions include the required information, as defined under the Board of Pharmacy Controlled Substance Rules (R 338.3161). Table 1 identifies the information required on all gabapentin prescriptions. Note that pharmacy law does not specify the maximum number of refills
Table 1: Gabapentin Prescription Required Information
Patient name and address
Prescriber name, address and professional designation
Prescriber DEA registration number1
Prescriber signature2
Prescriber telephone number2
Drug name
Drug dosage form
Drug strength
Drug quantity3
Directions for use
Date written
Refills authorized
1. All gabapentin prescriptions written under delegated authority shall include the name and DEA number of the prescriber along with the name and DEA number of the delegating prescriber. 2. Not required on oral prescriptions. 3. Drug quantity for a written prescription (“hard-copy”) shall be written in numerical terms and spelled out on the prescription or a boxed shall be checked to indicate the quantity written.
for a schedule V prescription. However, the DEA Pharmacist’s Manual states that refills for a schedule V are permitted, as authorized when the prescription is issued or if renewed by a practitioner. A prescription written for gabapentin expires in 12 months from the date written whereas a partially filled gabapentin prescription expires six months from the date written (R 338.3168). (See Table 1 above.) A prescription phoned-in for gabapentin can only be carried out between the pharmacist on duty and a prescriber (or an agent acting on behalf of the prescriber). However, a pharmacist may delegate a student pharmacist (intern) the authority to receive prescriptions for controlled substances under his or her supervision. The prescription must include the identity of the receiving pharmacist (or intern) as well as the identity of the individual calling in the prescription. Note that Section 17739 of the Michigan Public Health Code prohibits pharmacy technicians from receiving verbal prescription for controlled substances; therefore, a pharmacist shall not delegate such activity to a pharmacy technician.
R 338.3135 Licensees applying for or holding a controlled substance license, as well as delegates who prescribe, administer, or dispense on behalf of a licensee, will be required to complete a one-time opioid and other controlled substances awareness training. This requirement does not take effect until September 1, 2019, for initial licenses and the first renewal cycle after the promulgation of this rule for controlled substance license renewals. More details will be forthcoming from the MSMS Education Department as the compliance deadline nears. A complete copy of the new Pharmacy – Controlled Substances Rule Set is available on the Michigan Department of Licensing and Regulatory Affairs website at www. michigan.gov/bpl. If you have additional questions, please contact Stacey P. Hettiger, MSMS Director of Medical and Regulatory Policy at shettiger@msms.org or 517-336-5766.
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PNC full page ad (to come from Trish 2/20)
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FEATURE
Insurers claim that prior authorization requirements, including “fail first,” or “step therapy,” are designed to ensure patient safety and lower health care costs, but patients and physicians across the state are highlighting the urgent need for a patient-centered approach in health care that puts the needs of patients above bigger profits for insurers.
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FEATURE
Better Patient Care by Slashing Bureaucracy The Little Things Matter “Chester” the Chesapeake Bay retriever is a good sized canine, with a big heart, and he’s an animal Julia Burk counts on in and around her northern Michigan home. The little things matter, and Chester’s impact is even bigger than one might think. Julia – Jodi to friends – suffers from rheumatoid arthritis (RA), a debilitating autoimmune disease that causes an individual’s immune system to attack its own tissue. Typically, RA affects a patient’s joints. It’s been eating away at Jodi’s for years. She’s had her thumb fused, her wrist replaced, and endured three separate fusions in her neck as a result of the disease. Jodi, who makes her home in Bellaire, a small town north east of Traverse City, counts on her husband for love and support, her friends for prayer and understanding, and on Chester to keep her moving and active – from simple walks to snowshoeing during northern Michigan’s long winters. That began to change a year ago when her condition progressed, and the medicine she’d been taking became ineffective. Her energy level dropped, her pain increased, and she became symptomatic in new parts of her body. It became too painful even to take Chester for a walk. “That may not sound like a big deal to everyone else, but it’s a big deal to me,” said Jodi. She’s a responsible patient invested in her own care, so she scheduled an appointment with her physician. She sat for an exam and all of the appropriate tests, and developed a new plan of care designed to keep her on her feet—and holding Chester’s leash. Medical science hasn’t found a cure for RA just yet, but it’s developed many effective treatments for patients with different physiologies, severity of symptoms, and disease progression. Jodi’s physician prescribed a new medicine that would better treat her symptoms, and get her back on her feet. She had new hope—but then everything came screeching to a halt. Her physician contacted the insurance company to ensure they’d cover the medicine she needed and determine if an approval was required— a process insurers call “prior authorization.” The physician documented her patient’s condition, her previous experiences and medications, and explained why she was requesting a new prescription. A bureaucratic approval process that for many patients unnecessarily takes days or weeks has turned into a bureaucratic nightmare that has already kept Jodi Burk from effective treatment for more than a year. Her insurer, OptumRx, declined to cover the medicine Jodi needed until she’d failed first to respond to a variety of other drugs—some of them even newer and more expensive—with more prominent places on the insurer’s formulary.
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Prior Authorization and Step Therapy Insurers claim that prior authorization requirements, including “fail first,” or “step therapy,” are designed to ensure patient safety and lower health care costs, but patients and physicians across the state are highlighting the urgent need for a patient-centered approach in health care that puts the needs of men and women like Jodi above bigger profits for insurers. Betty Chu, MD, MBA, is a practicing OBGYN and the Chief Medical Officer and Vice President of Medical Affairs at Henry Ford West Bloomfield Hospital.
“Doctors have a desire to help relieve our patients’ suffering as quickly as possible. The absence of a diagnosis via imaging, or the inability to receive a needed drug, interferes with the treatment plan and the physician's ability to heal.” LISA MACLEAN, MD, DIRECTOR OF PHYSICIAN WELLNESS, HENRY FORD HEALTH SYSTEM
macy benefit managers and the rebates or usage deals they cut to move one medicine or another up or down a formulary. The delays can cause patients’ underlying conditions to worsen, or new symptoms to arise.
“Physicians’ oath to "first do no harm" implies that we will act to assist our patients A prior authorization demand sets phyin whatever way possible, as quickly as possicians and their staffs off on a time-consible,” said Doctor Chu, who also serves suming and expensive quest as they as the president of the Michigan State navigate requirements that differ from Medical Society. “Delays in care, once a insurer to insurer, and from decision has been made, lead product and plan to product to a diminishment of the docAs maddening and plan. Providers check tor-patient relationship as formularies, move through patients learn ‘someone else’ as the process step therapies, find the right they’ve never met is involved is for Michigan forms, chronicle the patient’s in the medical decision-makphysicians, it can medical history for insurance ing process. be devastating for company bureaucrats, print “Doctors have a desire to help and fill out paperwork, send their patients. relieve our patients’ suffering faxes—sometimes only to as quickly as possible. The learn that the authorization was denied, or absence of a diagnosis via imaging, or the that patients will have to try and fail to see inability to receive a needed drug, interimproved health under less effective treatferes with the treatment plan and the phyments for months or even years. sician's ability to heal.” As maddening as the process is for MichThat third-party bureaucracy, physicians igan physicians, it can be devastating for contend (and independent researchers their patients. agree), dramatically increases health care Jodi Burk’s time trial still isn’t over. Before spending while allowing some of the state’s authorizing the medicine she needs, Opsickest patients’ underlying conditions to tumRx has demanded that she try for two worsen, sometimes significantly. The more months each—and fail to experience imexpensive (and, often more effective) the proved health while taking—a long list of medicine or treatment, the more likely the other prescriptions first. She’s one year and insurer will require prior authorization. seven prescriptions into the bureaucratic However, many less expensive treatments swamp, and her health has continued to also get caught in the web of red tape bedeteriorate. cause of insurers’ relationships with phar-
“I am worthless as far as energy level,” said Jodi. “I hurt. I can’t sleep. I have gained thirty or forty pounds since this all started. This trial and error B.S. —it’s affected our whole household. “The longer I stay on a drug that doesn’t work, the ramifications of that…I’m spending dollars on a different medication or a medical procedure. They’re not saving anything by doing this. Not at all.” To the contrary. Burk’s health recently took a sharp turn for the worse, as symptoms moved to her lungs. While her disease most often affects the joints, in extreme progressions, it attacks internal organs as well. “If that is what’s happened to my lungs, and I can attribute it to the last couple years, now all the problems I have with my lungs are on the back of (my insurance company).”
The Patient Crisis Dozens of studies have been conducted over the last decade, examining the impact prior authorization has on patient outcomes. Each of them exposes a different level of patient devastation. PharmExec.com examined a number of the studies and found that when a prior authorization requirement is placed between a patient and the medicine his or her physician prescribes, less than 30 percent of those patients end up with original prescription.1 (CONTINUED ON PAGE 18)
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92%
of physicians claim that PA requirements had a negative impact on their patients’ health and wellbeing, according to a recent survey released by the Michigan State Medical Society.
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In other words, more than 70 percent of patients whose prescriptions are tied up in bureaucratic red tape never get the medicine their doctor believes they need.
resulting from nonadherence and other medical therapy failures annually comes in as high as $672.7 billion, and at the cost of 275,689 lives.
Staggeringly, 40 percent of these patients abandon their therapy.2 Whether it’s because of ineffective alternative medicines pushed by insurers, worsening symptoms and other health outcomes, frustration with a broken system, lack of trust in the middlemen pulling the strings or a multitude of other reasons, four in 10 patients that experience prior authorization bureaucracy simply give up and walk away from treatment.
“Prior authorization is potentially a deadly scenario,” said Mary Jo K. Voelpel, DO, FACOI, FACNM, a practicing hematologist and oncologist, and Associate Clinical Professor at Michigan State University’s College of Osteopathic Medicine. Late last year, Doctor Voelpel witnessed PA’s devastating effects first hand, over the course of treating an elderly cancer patient who was failing conservative therapies.
“I requested an oral chemo that is known According to a host of studies, that’s when to be well tolerated in the elderly and the problems really begin. Researchers creates transfusion independence and have repeatedly identified an “economic stability with good quality of life,” said backlash” created by prior authorization Doctor Voelpel. “His insurrequirements that extends far ance required prior authoribeyond the estimated $31 zation. We waited for approvMore than billion in compliance costs al and continued supportive borne by the nation’s physi70 percent of care. He became critically ill cian community.3 patients whose about six weeks after we had Perhaps the most widely cited requested the drug, and was prescriptions study, published in the Annals hospitalized and died three are tied up in of Internal Medicine, pegged days later. The next day the bureaucratic red the cost of nonadherence to drug arrived via mail. prescription medicines to the tape never get the “These stories are endless and nation’s health care system at medicine their the time required to complete up to $289 billion each year.4 doctor believes forms and answer queries is More costly is the human toll. endless. With this particular they need. The study’s authors estimate Staggeringly, 40 case we submitted the genonadherence contributes to netic documentation of the percent of these the deaths of 125,000 Amerneed three times. This entire icans each year. patients abandon process spanned over three their therapy. Prior authorization and step months. It became a win-win therapy requirements are an for the insurance company unmistakable part of that deadly equabecause they did not have to pay for his tion. 78 percent of physicians trace preuntimely death. Is this the way we pracscription and treatment non-adherence to tice medicine?” prior authorization delays.5 Patient risk is an unmistakable and They’re numbers that take physicians’ sometimes debilitating—or even deadbreath away—but they may be only the tip ly—“side effect” of insurance company of the iceberg. A more recent study pubprior authorization practices. lished in the Annals of Pharmacotherapy6 A recent survey released by the Michigan pegged the costs of nonadherence in an enState Medical Society asked physicians tirely different stratosphere. across the state what kind of an impact PA Researchers estimated the cost of prescripbureaucracy had on their patients. Neartion drug-related morbidity and mortality ly three-in-four reported that PA delayed
“As a doctor, I do not want [my patient] on a more risky, more dangerous drug, when a much-safer drug has been proven to do a fantastic job of completely controlling all of the disease symptoms.” IRENE KAZMERS, MD – MSMS LIAISON COMMITTEE MEMBER
treatment for their typical patients by at least a day, but with an important and dangerous outlier. Nearly 38 percent said they wait three days or longer to get even basic approvals for the medicines, tests, or treatments their patients need.7 So it isn’t surprising that another study found 92 percent of physicians claim that PA requirements had a negative impact on their patients’ health and wellbeing.8
According to Doctor Kazmers, Coffey’s coverage request is going through a lengthy appeal process and her insurer has provided no indication how long they might take to make a decision.
“Her insurer is requiring she be switched to an immunosuppressive drug that will increase her risk for infections and potentially fatal diseases like pneumonia,” said Doctor Kazmers, a Northern Michigan rheumatologist and member of the Michigan State Medical Society Liaison Committee with Third Party Payers. “She has no side effects from the safer medicine I’ve prescribed. As her doctor, I do not want her on a more risky, more dangerous drug, when this much-safer drug has been proven to do a fantastic job of completely controlling all of her disease symptoms.”
of all first-time
prior authorization
“It would be medically wrong to switch her to the more dangerous drug for no good reason,” said Doctor Kazmers. risk is
requests are eventually
Coffey is equally matter of fact. “It makes me very angry and confused,” she said. “I don’t understand why they would want you to take something that may increase other costs (because of regular testing and additional treatment to address side effects). Before I had this medicine, I couldn’t do anything. I ached constantly. Within six weeks of starting the medicine Doctor Kazmers prescribed, the ache went away. I’ve even quit taking nighttime Tylenol—haven’t taken it for more than a year.”
Association. In other
Patient an unmistakable and sometimes debilitating— or even deadly— “side effect” of insurance company prior authorization practices.
Elizabeth Coffey is a 62 year old from Indian River battling a variety of health conditions. Her physician, Irene Kazmers, MD, identified an effective treatment that helped Coffey reclaim her life, but her insurer refuses to cover it. Instead, they are requiring her to take another drug with numerous serious side effects.
97.5% approved, according to the American Medical words, insurers are delaying patients’ access to care for essentially no reason.
Without approval from her insurer, Coffey relies on her physician’s supply of drug samples to provide the treatment she needs. “I have to call the office to see if there are any samples available, then drive 40 minutes each way to pick them up,” said Coffey. That’s hardly a sustainable approach. (CONTINUED ON PAGE 20)
MARCH / APRIL 2019 |
michigan MEDICINE® 19
What’s more, many of these sorts of delays are ultimately meaningless—even for insurers. 97.5 percent of all first-time prior authorization requests are eventually approved, according to the American Medical Association. In other words, insurers are delaying patients’ access to care for essentially no reason.9 Kevin O’Neill is the Vice President of Revenue Cycle at Henry Ford Health System (HFHS). His team helps connect the dots between area patients and the medicines and treatments prescribed by their physicians. “Payers continue to increase prior authorization requirements, even for services that are approved for authorization over 95 percent of the time,” said O’Neill. “HFHS (alone) obtained over 200,000 payer prior authorizations for scheduled services in 2018, not including inpatient services where patients were admitted through the emergency department. This volume represents an increase of over 35 percent from 2016.” According to O’Neill, after an initial request, payers can take up to 14 days to provide authorization. “Delaying care can have significant negative impacts for a patient including both clinical and non-clinical and emotional issues,” he said.
“Insurers need to eliminate prior authorization for physician and provider networks, improve feedback to providers, and adopt a 24/7 methodology to review prior authorization.” BETTY S. CHU, MD MSMS PRESIDENT
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Health Can’t Wait
being into a process from which payers never should have excluded it. They’re also pushing for reforms to ensure continuity of It’s no surprise then, that patients are decare, transparency and fairness, timely acmanding a fix. They’re clamoring for somecess and administrative efficiencies to cut one on the payer side of the equation to the wait times and diminish rampant prelisten to them—to see them as a person, scription drug nonadherence, and for the not a line item on a budget sheet. creation of alternatives and ex“I would explain to my insuremptions for the patients who Providers er—if they would listen—what need them most. my family has gone through and advocacy “Eliminate prior authorization and what I’ve gone through,” groups across for physician and provider said Burk, the northern MichiMichigan have networks to reinforce qualigan patient struggling to access ty of care,” said Doctor Chu. come together the treatment she needs for “Insurers are also going to rheumatoid arthritis. “Pain. to launch an need to improve feedback to Sleeplessness. No energy to unprecendented providers regarding the ratioparticipate. I would make coalition push nale for claims denials in real plans with friends then have time. Insurers need to adopt for meaningful to cancel because I couldn’t do a 24/7 methodology to reit. I want them to understand change. view prior authorization. Our the mental anguish of being in health care facilities and patients are seekpain all the time. ing answers quickly, and they’re not always “Until someone has pain like this, and doing it between nine and five.” they can’t get away from it, you don’t unElizabeth Coffey’s message to insurers is derstand. I was on a medicine for 10 years simple. “How dare you. This is my life and and it worked wonderfully. All of a sudden, my body. My physician prescribed a drug (my insurer) says they aren’t covering it that works. How dare you tell me I can’t anymore. That’s a pretty nasty thing.” take this when it’s safer than the one you’re That’s why providers and advocacy groups trying to push on me. Who are you? You’re across Michigan have come together this not a doctor.” spring to launch an unprecedented coaliMichigan’s physicians and patient advotion push for meaningful change. Payers cates believe Coffey’s is a message whose haven’t listened, so they’re taking their case time has come. to state policymakers. Groups like the Michigan State Medical Society, Michigan Academy of Family Physicians, Michigan Radiological Society, Michigan Rheumatism Society, Michigan Society of Hematology & Oncology, Michigan Physical Therapy Association and many others, including patient advocacy groups, are on the ground at the state Capitol unveiling to lawmakers a reform push called Health Can’t Wait. Physicians and other health care providers within each organization are advocating in Lansing on behalf of patients for a number of common sense reforms. They’re demanding PA and step therapy requirements be remodeled to ensure clinical validity, reinserting the patient’s well-
REFERENCES 1 http://www.pharmexec.com/tackling-priorauthorization-challenge-critical-task-pharma 2 http://www.pharmexec.com/tackling-priorauthorization-challenge-critical-task-pharma 3 http://www.hii.iu.edu/the-prior-authorizationburden-in-healthcare/ 4 https://www.nytimes.com/2017/04/17/well/thecost-of-not-taking-your-medicine.html 5 https://healthpayerintelligence.com/news/priorauthorization-issues-contribute-to-92-of-caredelays 6 https://www.pharmacytimes.com/contributor/ timothy-aungst-pharmd/2018/06/doesnonadherence-really-cost-the-health-care-system300-billion-annually 7 MSMS 2017 SURVEY 8 https://www.ama-assn.org/press-center/pressreleases/survey-patient-clinical-outcomesshortchanged-prior-authorization 9 https://www.ama-assn.org/practice-management/ sustainability/how-prior-authorization-hobblesbreast-cancer-care
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michigan MEDICINE® 21
THE FUTURE OF HEALTHCARE: A NATIONAL SURVEY OF PHYSICIANS
Doctors Conflicted, but Patients Still Top Concern By Bill Fleming, Chief Operating Officer, The Doctors Company
Physicians are concerned about the quality of care they provide to patients— that is, after all, the reason they chose the profession. But physicians today report being so disappointed with the present state of medical practice, that 7 out of 10 say they cannot recommend the profession to their children or other family members.
T
hat’s the message from the 2018 Future of Healthcare survey, featuring responses and comments from more than 3,400 physicians nationwide. Conducted by The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, the survey reveals a complicated picture about the attitudes of physicians towards the state of healthcare. The survey results indicate that in the future, healthcare will likely be much different than what providers and patients are accustomed to today. The number of physicians may continue to decrease, with fewer entering the profession and many practicing physicians retiring in the next five years. Patients may no longer see a physician for non-critical conditions, as advanced practice providers such as nurse
practitioners and physician assistants will likely fill the gap. And while practice consolidation appears to have slowed, evolving technologies and reimbursement models are viewed as encumbrances to the most important reason doctors practice medicine: caring for patients.
Below are some of the survey's most relevant findings:
54% believe current electronic health record (EHR) technology is having a negative impact on the physician/patient relationship. 62% say they don’t plan to change practice models within the next five years. 54% contemplate retirement within five years due to changes in healthcare.
54%
62%
54%
BELIEVE CURRENT ELECTRONIC HEALTH RECORD (EHR) TECHNOLOGY IS HAVING A NEGATIVE IMPACT ON THE PHYSICIAN/PATIENT RELATIONSHIP.
OF DOCTORS SAY THEY DON'T PLAN TO CHANGE PRACTICE MODELS WITHIN THE NEXT FIVE YEARS.
OF DOCTORS CONTEMPLATE RETIREMENT WITHIN FIVE YEARS DUE TO CHANGES IN HEALTHCARE.
22 michigan MEDICINE®
| MARCH / APRIL 2019
Contributed by The Doctors Company
thedoctors.com
SEVEN OUT OF 10 PHYSICIANS ARE WILLING TO RECOMMEND HEALTHCARE AS A PROFESSION.
And physicians were clear in their comments. “If I had to start today, I would choose another field of endeavor,” said one. Another opined, “We love what we do, but…we need to restore the dignity back to the physician-patient relationship.” While many say they are disheartened with medicine, it gives us hope that the unique passion physicians possess for patient care remains. As one California surgeon noted: “There is no other life I would choose, regardless of compensation or regulation.” Despite the cautionary notes these results strike for the future, they still give some reason for optimism. Younger doctors shared a more positive perspective of EHRs. Moreover, after a period of relative flux in practice models, doctors now an-
“Clearly changes are coming. I hope physicians can focus on helping patients while managing a balanced lifestyle to ensure that their personal needs are adequately attended to.”
ticipate that their practice settings will stabilize over the next five years. The vast majority say they will not change practice models in the near future. This structural solidification may give patients more reassurance and predictability when it comes to their healthcare experiences.
What can be done to reverse some of the disenchantment? Based on the responses to this survey, we need to think long-term. Physician disenchantment may ultimately change the face of healthcare as we know it. As it stands today, by 2020 we will already reach a tipping point, with more primary care physicians retiring than graduating from primary care residencies across the US. From this alone, we can predict a re-
“There is a need for integrated EMR connecting hospitals and doctor offices. Documentation and compliance could be automatically obtained and not require redundant input and authorizations.”
shaping of services, with physician assistants and nurse practitioners composing more of the family practice workforce. The medical profession is emerging from a period of uncertainty. The use of EHRs is finally becoming familiar, if not popular. And though new business structures and pricing methods might not be second nature, the challenges are at least better understood. To help advance the practice of good medicine, surveys like the Future of Healthcare are instructive and vital. Doctors deserve a loud voice in the healthcare debate, so that quality care and the doctor-patient relationship are the cornerstone of every decision.
“The Federal government should leave the practice of medicine to physicians. The increased regulatory demands of valuebased medicine are overwhelming.”
MARCH / APRIL 2019 |
michigan MEDICINE® 23
Properties for Sale MEMBERS OF THE MICHIGAN STATE MEDICAL SOCIETY REMEMBER THEIR COLLEAGUE WHO HAS DIED.
HAROLD E. BOWMAN, MD INGHAM COUNTY MEDICAL SOCIETY 2/1/2019
x TO MAKE A GIFT OR BEQUEST: CONTACT REBECCA BLAKE, DIRECTOR MSMS FOUNDATION CALL 517-336-5729 OR EMAIL RBLAKE@MSMS.ORG
MSMS FOUNDATION’S 8TH ANNUAL
COSMETIC SURGERY CENTER IN ANN ARBOR Physician and former instructor wishes to phase out. Working 4 easy days and still grossing over 1 million. Approved O.R., several lasers and other useful cosmetic machines for noninvasive treatments. 35 years of good reputation built a word of mouth practice with virtually no advertisement. Physician would like to pass on recent marketing ideas to next owner that work well with little or no expense. Nice medical condo, well equipped, good staff. Asking $350K for business and $410K for real estate. Transition period definitely offered. ADDICTION MEDICINE/ FAMILY PRACTICE IN ALLEN PARK/ SOUTHGATE AREA At 75 current owner would like cover for the new owner when needed. Started years ago as Family Practice, then doctor was Boarded in Addiction Medicine. This business is both with more revenue coming from Addiction Medicine—very little Pediatrics under 10 yrs. Clean, above board practice. Many insurances accepted and room for expansion of business. Ten exam rooms, labs, x-ray, two mid-levels and roomy building with parking lot. Grossing over 1.3 Million. $360K for practice. Flexible terms on real estate.
THURSDAY, MAY 16 – FRIDAY, MAY 17, 2019 DOUBLETREE HILTON DEARBORN
INTERNAL MEDICINE PRACTICE IN DEARBORN ON MAIN ROAD Details are still being worked out, will be offering this 25+ YEARS practice by the time this magazine is published. Clean, no Opiate seekers. Medicare population, mostly with chronic conditions. Larger clinic would nicely fit two physicians at a time. Will be competitively priced. Arabic speaking would be a benefit. INTERNAL MEDICINE PRACTICE IN TAYLOR ILLNESS FORCES SALE. Practice was $850K grossing now around 20% of that, working 1 ½ days a week. We want to work out a win-win deal with a Physician to take over. Get a great start, should bounce back once more coverage is offered. Open to offers. URGENT CARE IN WESTLAND Open an Urgent Care and lose money for two years is the norm. Ours, after 18 months and advertising, is turning a profit and climbing from repeat patients. Why not get dual providers? Build on what is now a sharp and functional business. Owner has been offered a substantial new position and doesn’t want to sell his “baby” to just anyone. Terms offered to the right doctor or doctors to take over.
Union Realty Joseph M. Zrenchik, Broker Call 248-240-2141 Call Joe for ideas and advice on Buying, Building or Selling a Practice
16.25 24 michigan MEDICINE®
| MARCH / APRIL 2019
#SSM2019
28 YEARS EXPERIENCE
MARCH / APRIL 2019 |
michigan MEDICINE® 25
Educational Offerings MSMS On-Demand Webinars
For a complete listing of On-Demand Webinars visit:
Webinars Offering CME:
Free CME Webinars:
Balancing Pain Management and Prescription Medication Abuse: Chronic Pain and Addiction*
2018 Prescribing Legislation* (part of the Pain and Symptom Management Series)
CDL-Medical Examiner Course
Choosing Wisely Part 1 - Stewards of our Health Care Resources
From Physician to Physician Leader
Choosing Wisely Part 2 - Change Strategies to Implement Choosing Wisely
HEDIS Best Practices
Health Care Providers' Role in Screening and Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities
HIPPA Security and Meaningful Use Compliance Human Trafficking*
In Search of Joy in Practice: Innovations in Patient Centered Care
Inter-professionalism: Cultivating Collaboration
Legalities and Practicalities of HIT - Cyber Security: Issues and Liability Coverage
Medical Ethics – Conscientious Objection among Physicians*
Legalities and Practicalities of HIT - Engaging Patients on Their Own Turf: Using Websites and Social Media
Opioids and Michigan Workers' Compensation Webinar Patient Portals as a Tool for Patient Engagement
MACRA Series
Pain and Symptom Management Series*
Key Things You Should Know About MACRA
Pain and Opioid Management 2017*
Roadmap for Getting Started
The CDC Guidelines*
MACRA: Alignment Strategy
Treatment of Opioid Dependence*
The Role of Documentation
The Role of the Laboratory in Toxicology and Drug Testing*
Technology Survival Tips to Tackle MACRA
Michigan Automated Prescription System (MAPS) Update
Navigating Need to Know Resources
MAPS Update & Opportunities The Current Epidemic and Standards of Care Balancing Pain Treatment and Legal Responsibilities Physician Online Rating and Reviews: Do's and Don'ts Preparing for the Medicare Physician Value-Based Payment Modifier What's New in Labor and Employment Law *Fulfills Board of Medicine Requirement
26 michigan MEDICINE®
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MACRA’s Quality Payment Program: Highlights for 2018
Taking Control of MACRA with a QCDR Michigan Automated Prescription System (MAPS) Update* (part of the Pain and Symptom Management Series) MAPS Update and Opportunities* (part of the Pain and Symptom Management Series) Section 1557: Anti-Discrimination Obligations Understanding and Preventing Identity Theft in Your Practice
*Fulfills Board of Medicine Requirement
Visit msms.org/OnDemand for complete listing of On-Demand Webinars. Register online at msms.org/eo or call the MSMS Registrar at 517-336-7581.
msms.org/OnDemand
Coding and Billing Webinars Billing 101 Claim Appeals Complete Coding Updates for 2018 Compliance in the Office Credentialing ICD-10 for 2017 & Routine Waiver of Co-pays ICD-10 What We Have Learned & What We Need to Know
Upcoming Educational Conferences – REGISTER TODAY! A Day of Board of Medicine Renewal Requirements Date: Friday, May 3 Location: Radisson Plaza Hotel and Suites, Kalamazoo Note: Continental breakfast and lunch will be provided. Intended for: Physicians and all other health care professionals. Contact: Beth Elliott at 517/336-5789 or belliott@msms.org
2019 Spring Scientific Meeting Morning, afternoon and evening clinical courses available
Managing Accounts Receivable
Date: Thursday, May 16 and Friday, May 17
Reading Remittance Advice
Location: DoubleTree Hotel, Dearborn
Tips and Tricks on Working Rejections Year-End Wrap Up
Note: Continental breakfast and lunch will be provided Intended for: Physicians and all other health care professionals Contact: Marianne Ben-Hamza 517/336-7581 or mbenhamza@msms.org
*Fulfills Board of Medicine Requirement
Medical Necessity – Tips on Documentation to Prove it Date: Thursday, May 16 Location: DoubleTree Hotel, Dearborn Intended for: Physicians, Administrators, Office Managers, Coders, Billers and all other health care professionals. Contact: Marianne Ben-Hamza 517/336-7581 or mbenhamza@msms.org
Documentation for MACRA & HCC. Date: Thursday, May 16 Location: DoubleTree Hotel, Dearborn Intended for: Physicians, Administrators, Office Managers, Coders, Billers and all other health care professionals. Contact: Marianne Ben-Hamza 517/336-7581 or mbenhamza@msms.org
Register online: www.msms.org/eo Or call: 517-336-7581 michigan michiganMEDICINE® MEDICINE® 27
MARCH MARCH / APRIL / APRIL 2019 2019 | |
Welcome New Members Bay
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Oakland
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(CONTINUED ON PAGE 30)
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Robert Fields, DO
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