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Spring 2017

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CONTENTS Spring 2017

Volume 77

Number 1


4 As health care landscape changes,

ON THE COVER: In this third part of the series on the PAFP’s work with the Pa. Dept. of Health, we discuss the Penn Family Medicine Residency Program in Philadelphia, the vital primary care services it provides with an underserved population in the West Philadelphia community, and the importance of primary care funding.


PAFP on the front lines


6 Feeling a bit chili this winter?; CHOP looking for autism research participants; Atlantic Health Partners – Your Flu and Vaccine Partner!


16 Cover Story: Primary Care Workforce Development Part III: Penn Family Medicine Residency Program


10 Government Affairs: State Rep. Marguerite Quinn leads prior authorization reform; Advancing the agenda: An interview with Dr. David O’Gurek

26 Legal and Compliance Update:

37 10

Complex chronic care management; new Medicare reimbursement rules; incident-to direct supervision exception; Retroactive Denial of Reimbursements Act: Act 146 of 2016


28 Have you or a colleague done something worth bragging about?

32 Online CME Catalog

President’s Message PA Academy of Family Physicians & Foundation


2704 Commerce Drive, Suite A Harrisburg, PA 17110 717-564-5365 • TOLL FREE 1-800-648-5623 • FAX 717-564-4235 EDITOR-IN-CHIEF/CHIEF COMMUNICATIONS OFFICER Michael Zigmund ( MANAGING EDITOR/DIRECTOR OF MEDIA AND PR Bryan Peach ( Keystone Physician, member magazine of the PA Academy of Family Physicians, is digitally published four times a year. Editorial opinions and advertisements in this publication do not necessarily reflect the views of the PAFP and Foundation, unless so stated. © 2016. Unless stated otherwise, nothing may be reproduced either wholly or in part without permission from the Editor-in-Chief.

EXECUTIVE VICE PRESIDENT John S. Jordan, CAE ( STAFF Deputy Executive Officer / Chief Operation Officer Brent Ennis ( Chief Education Officer Janine Owen ( Chief Financial Officer

As health care landscape changes, PAFP on the front lines In my last column for Keystone Physician, I wrote about mentoring, that important relationship that helps to discover, encourage, and develop new physicians. Since that column, we have lost a giant in family medicine: Richard Kuhn, MD, formerly the residency director of the St. Vincent Family Medicine Residency Program. Dr. Kuhn was a mentor for so many students and residents – a kind and generous man who taught us the humility of medicine by his actions. A great storyteller, he could wrap a teaching lesson into any story to use the moment to help someone learn from the story. Every moment was an opportunity to teach, for knowledge readied us for what was to come.

Karen Runyeon ( Director of Resident and Student Initiatives Molly Talley ( Director of Education Lindsey Killian (

2015-16 OFFICERS PAFP President ( Robert Rodak, DO (Erie) PAFP President-Elect Edward Zurad, MD (Tunkhannock) Foundation President Mary Stock Keister, MD (Fogelsville) PAFP and Foundation Treasurer Chris Lupold, MD (Lancaster) PAFP Board Chair and Immediate Past President Nicole Davis, MD (Philadelphia)

DELEGATES TO THE AAFP CONGRESS Bradley Fox, MD (Fairview) Madalyn Schaefgen, MD (Allentown) Alternate — Dennis Gingrich, MD (Hershey) Alternate — Kevin Wong, MD (Jeannette)

BOARD OF DIRECTORS D. Scott McCracken, MD (York) Pamela Valenza, MD (Bethlehem) James Joseph, MD (Cattawissa) - Foundation Vice President Mary Stock Keister, MD (Fogelsville) - Foundation President Tracey Conti, MD, (Monroeville) Jason Woloski, MD (Hershey) - Resident Chair

For over 20 years, Dr. Kuhn impacted the lives of his residents in the St. Vincent Family Residency Program, helping develop the caretakers of the future, family physicians. Even after retiring as residency director, you could see him in the halls with students and residents as their preceptor. His love for family medicine was contagious and his ability to impart the knowledge of medicine was superb. Like he was for so many others, he was my mentor, for which I am so grateful. So as in everything, there must be change. This seems particularly apparent this last year, even with the Pennsylvania Academy 4 | Keystone Physician | Spring 2017

Clayton Cooper - Student Chair

of Family Physicians. If you were not aware, the PAFP moved to a complete “virtual office” and has sold its building – although an asset, it was also quite an expense. Rather than having the members continuing to bear the cost, our virtual office has been in operation for almost a year, with members getting the same great service as they have had in the past. As the health care landscape changes, the PAFP has been on the front lines on issues like residency expansion program, collaborative agreements with nurse practitioners, medical marijuana, and the opioid crisis. As in the past, we acknowledge the importance nurse practitioners play in the role of our family

bution and sales licenses for medical marijuana. Unfortunately, not much evidence-based standards of care have been written research restrictions, but we expect more information to come. The opioid crisis is of much concern and is requiring many resources from medicine and law enforcement. The state’s prescription drug monitoring program (PDMP) has been in effect since last year, and as you all are aware, requires inquiry for each patient you write for an opioid or benzodiazepine. This is a labor-intensive process, and I hope our legislators are watching the data to see if such a process has an impact on how prescriptions are misused or diverted. I also hope it helps in identification of those needing help, and that the state can provide the neces-

RESIDENCY EXPANSION • COLLABORATIVE AGREEMENTS NURSE PRACTITIONERS • MEDICAL MARIJUANA • OPIOID CRISIS medicine care teams. Our patients depend on us and them for education and care. The PAFP believes the collaborative agreement is necessary to help define the expectations of our roles. Our patients are assured the highest standard of their care by these agreements. This is an item our state legislators are working on and with the help of Brent Ennis, PAFP deputy executive vice president, we will continue to advocate for the best care for our patients. Medical marijuana is also on our radar. With the passage of last year’s legislation, coming this March, businesses can apply for growing, distri-

sary resources for these programs to make them effective. The PAFP has been active in multiple committees being held by various state organizations considering this problem. We as an Academy continue to grow, with more than 3,214 active members (up 2 percent), resident members of 813 (up 1 percent), and student members of 1,789 (up 12 percent). I would like to personally welcome all of you to the Harrisburg CME Conference this year in collaboration with Penn State Health, March 16 through 19. We hope to see you there! | 5

Member News

Feeling a bit chili this winter? The PAFP’s Harrisburg CME Conference weekend tastes a little bit different than past events, thanks to an exciting PAFP Foundation fundraiser to benefit PAFP Foundation education, resident, and student initiatives: the PAFP Chili Cook-off! Residency programs and family medicine interest groups (FMIGs) are invited to form teams and submit a chili recipe to the competition. No need to do the shopping or cooking – the Hilton staff will prepare your recipe as instructed for the event. So get creative and have fun! Team representatives will promote their entry at the event and rally support networks for monetary votes

(online voting and donation will be available, so leverage your social media network!). Learn more and submit your team’s recipe here.

CHOP looking for autism research participants

Atlantic Health Partners – Your Flu and Vaccine Partner!

The Children’s Hospital of Philadelphia (CHOP) is looking for participants in its ECHO Autism project, a six-month experimental research study that allows primary care physicians to confidently identify and treat autism. Physicians participate in study clinics and complete questionnaires and get regular access to autism experts at CHOP while learning about evidence-based autism intervention, common medical concerns in children with autism, and successful office visits for children with behavioral concerns. Click here for more information and to sign up.

As you may know, Atlantic Health Partners is the nation’s leading vaccine buying group and works with many of our members. Atlantic offers PAFP practices the most favorable terms for Sanofi and Seqirus flu products, and can help you best plan for flu season.

6 | Keystone Physician | Spring 2017

In addition, Atlantic also offers our members the best pricing for the complete range of Merck and Sanofi vaccines. In short, working with Atlantic will improve your ability to effectively and efficiently provide immunizations to your patients and strengthen your practice performance. We encourage you to contact Atlantic to see how they can assist your practice. Their contact information is 800-741-2044 or


The Combined

PAFP CME Conference & Penn State Health... Primary Care Across the Lifespan MARCH 16 - 19, 2017 Hilton Harrisburg • Harrisburg, PA Please join us as PAFP and Penn State Health combine for an exceptional educational and social event. This program offers outstanding quality programming in various formats that’ll appeal to the most discerning learner, with actual patient participation and hands-on learning. The Inauguration of PAFP’s incoming President Edward Zurad, MD, Research Day activities and Annual Business Meeting, along with social highlights, a Penn State Alumni reception and Chili Cook-off round off this memorable weekend in Harrisburg. FAMILY AND COMMUNITY MEDICINE AT


Course Directors • • • • • •

Drew Keister, MD Michael Gaudiose, MD Gus Geraci, MD Dennis Gingrich, MD William Hennrikus, MD Lindsey Killian

• • • • • •

Madhu Menon, MD Janine Owen Robert Rodak, DO Mack T. Ruffin, IV, MD Kathleen Sweeney, DO Jeffrey Zlotnick, MD

Join us for the installation of the incoming PAFP President, Edward Zurad, MD and officers followed by the President’s Reception and Dinner Gala. Penn State Alumni Social - Saturday, March 18 6:30 - 7:30pm Relax and unwind with fellow Penn State College of Medicine alumni colleagues over hors d’oeuvres and beverages. Sponsored by: Pennsylvania Academy of Family Physicians and Foundation


Penn State Health

Will You Be the 2017 Chili Champion? Be Sure to Enter the Chili Cook-off at PAFP's March CME Meeting

Visit the beef booth for nutrition information, recipes and more. 8 | Keystone Physician | Winter 2016

Harrisburg CME Conference March 16 - 19, 2017

Reading CME Conference November 17 - 19, 2017

Reading CME Conference Friday November 17, 2017

Topic: TBD

Improving Provider-Patient Engagement by Optimizing Communication 1 credit(s)

DOT Medical Examiner Training (Online Audio) 6.5 credit(s) | 9

Visit details on all of our CME offerings

Government Affairs BRENT ENNIS, Deputy Executive Officer / Chief Operation Officer

State Rep. Marguerite Quinn leads prior authorization reform First elected in 2006 to the State House of Representatives representing parts of Bucks County, Rep. Quinn (R) began last year to focus her sights on reforming prior authorizations on medical services in Pennsylvania. Working with state stakeholders including the PAFP and researching efforts around the nation, Rep. Quinn has crafted legislation that would focus on streamlining and standardizing the process. It calls for maximizing electronic communications for authorizations as well as adverse determinations, and for the creation of a panel to develop a standardized form each insurer must use. Further, it would define consistent response times for authorizations, rejections, appeals, and external utilization review.

State Representative Marguerite Quinn (R)

The effort is supported by the PAFP. As the leadership of PAFP’s Government and Practice Advocacy Committee (GPAC) attests, the reforms are sorely needed. “The prior authorization process as it currently stands serves as the administrative red tape that interferes with patients getting the right care at the right time,” said Dr. David O’Gurek, Chair of the GPAC and faculty physician at Temple University. “With different forms for insurers and different forms within a particular insurer for specific medicines, variations on what supporting materials must be submitted to different insurance companies, and delays in processing requests by

Sue Fidler, MD Vice Chair of GPAC and faculty physician at Abington Family Medicine Residency

10 | Keystone Physician | Spring 2017

David O’Gurek, MD Chair of the GPAC and faculty physician at Temple University

insurers, significant time investment on the part of physicians and staff is needed to ensure a seamless process is in play. “It can seem like a tireless and pointless game back and forth while the patient suffers without a medicine that evidence has demonstrated would be effective in treating his or her condition,” said O’Gurek. “The process is more complicated than it needs to be, perhaps with the intent to deter physicians from even going through the process. Legislation to streamline this process or make it easier on the part of physicians is long overdue.” Dr. Sue Fidler, Vice Chair of GPAC and faculty physician at Abington Family Medicine Residency, further detailed the extent of the problem. “The current prior authorization process is yet another hurdle for physicians to overcome in the battle to spend more time with their patients. It is

an administrative burden that can consume hours each week of staff and physicians time,” she said. “All physicians will always choose spending time with patients, over completing forms or waiting on hold for a ‘peer’ to determine what’s best for our patient. “There is lack of standardization across insurers,” Fidler continued. “Oftentimes, the requirements for approval contradict the best of evidence-based medicine or logical clinical care pathways and always prevent patients from getting what they need in a timely fashion.” Rep. Quinn understands the issues and looks forward to seeing her legislation advance. “At the end of the day, this is about improving patient care by reducing bureaucracy,” said Quinn. “I believe my legislation will go a long way in improving medical services for all Pennsylvanians.”

T h e Pe n n sylva n ia Ac a d e m y o f F a m ily P hy s i ci ans

Political Action Committee | 11 | 11

Government Affairs

Advancing the agenda: An interview with Dr. David O’Gurek Chair of the Academy’s Government and Practice Advocacy Committee (GPAC) and Faculty Physician at Temple University. Dr. O’Gurek, what are some of the fundamentals of how the Government and Practice Advocacy Committee (GPAC) approaches its work? GPAC’s function is to maintain the pulse on legislative and practice issues, both ongoing and in the pipeline that will affect our members and the patients we serve in the Commonwealth in both a reactive and proactive mechanism. With nearly 1,000 state bills introduced each session involving health care, this is no small task, and we are lucky to have the expertise and experience of our own Brent Ennis [PAFP Deputy Executive Vice President and COO] to assist us in navigating this process. With such a significant legislative agenda, part of our task is monitoring and vetting through all those proposals and developing priorities for the Academy. It is critical, however, that our priorities are developed with our members in mind; therefore, we appreciate members engaging with us and leadership on issues affecting them, their practices, and their patients so that we can appropriately align our efforts to be in the best interests of the Academy’s members. 12 | Keystone Physician | Spring 2017

What issues have GPAC and the PAFP Board of Directors identified for the 2017-18 legislative session? At this time, there are four key legislative issues we are focused on at the onset of this legislative session. We support credentialing reform (House Bill 125), prior authorization reform, and are proactively developing and seeking sponsorship for direct primary care (DPC) authorization legislation. We remain opposed to legislation that would eliminate collaborative agreements with advanced practice nurses (APRNs) (click here for the Senate co-sponsorship memo) and remain

committed to our goal of quality care delivered to advance community and population health through a physician-directed patient centered medical home (PCMH). At our next meeting, we’ll be looking at legislative issues surrounding telemedicine and Pennsylvania Orders for Life-Sustaining Treatment (POLST). While there are certainly many more issues out there, it’s a balancing act, and this docket alone is quite lofty. There certainly is an opportunity cost with choosing a specific issue, as getting involved in too many issues can dilute our effectiveness.

Does GPAC address federal health care issues? GPAC does not specifically address federal health care issues; however, this does not imply that we do not see a critical role for our members in engaging in advocacy regarding federal legislation affecting them or the patients they serve. The American Academy of Family Physicians leads the way on federal issues, having its own Governmental Advocacy Commission, as well as an entire team situated in Washington addressing issues facing the specialty and our patients. Furthermore, opportunities such as the Family Medicine Congressional Conference, State Legislative Conference, and SpeakOut are venues and opportunities for our members to engage in the national discussion on federal health care issues. Our task is to focus on state issues, and as noted, to do so strategically given the significant docket of issues that can be addressed. While state matters often do not garner the same level of media attention, they are many times just as impactful on our profession from scope of practice to mandatory practice requirements. Furthermore, our engagement in state level politics

has established our Academy as a respected and valued opinion within the Commonwealth on health care issues.

How important is grassroots support and advocacy by members? As the adage goes: “all politics is local.” Our members, including our students and our residents, are uniquely positioned to have the ear of their local legislators and therefore their roles in grassroots advocacy are so very critical. After all, these legislators are part of the communities we serve, and given that our members have a true pulse on issues related to health within these communities, they are an incredible wealth of information for the men and women in Congress. With 50 state senators and 203 representatives who serve full time, Pennsylvania’s legislature is among the largest and most active legislatures in the country, only matched by California and New York in size and session length. Therefore, it is key for members to know and engage their local senator and representative.

Lastly, where do members get the latest information on PAFP’s legislative agenda? PAFP Connect is the online community for members only where you can join the Government and Practice Advocacy Committee’s group. This portal was created a few years ago to provide information on all of PAFP’s activities in a secure and confidential environment. Progress Notes also contains bi-weekly updates, and Keystone Physician includes pertinent updates on both legislative and practice advocacy issues. We remain committed to advocacy issues, and at times, the PAFP issues special advocacy emails. We always encourage members to directly contact leadership regarding specific issues and for those interested in getting more involved, opportunities exist to serve on the PAFP’s GPAC. | 13

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Margaret Baylson, MD, MPH Assistant Professor of Clinical Family Medicine and Community Health 16 | Keystone Physician | Spring 2017




n 2014, the Pennsylvania Academy of Family Physicians received a grant from the Pa. Dept. of Health’s Bureau of Planning. That grant, part of the bureau’s Primary Health Practitioner Program, led to a new investment in primary care workforce development through a PAFP-administered project supporting family medicine residency expansion. The objective of the grant was to increase the number of family physicians who train in and remain in Pennsylvania communities experiencing a critical shortage of primary care physicians. In this third part of the series on the PAFP’s work with the Pa. Dept. of Health, we discuss the Penn Family Medicine Residency Program in Philadelphia, the vital primary care services it provides with an underserved population in the West Philadelphia community, and the importance of primary care funding including the three new residency slots funded by the primary care workforce development investment.



PART II | 17

In the heart of West Philadelphia, the University of Pennsylvania’s Family Medicine and Community Health department takes care of its underserved community with a decidedly more intimate approach than one might expect in the fifth-largest city in the United States. It underscores what residents often say about the City of Brotherly Love – that it’s in fact a large series of interconnected communities; for the Penn Medicine Family Medicine Residency Program, “community” is in fact the operative term.

“They can get both in one setting, and I think that’s really appealing to a lot of fourth-year medical students who are applying in family medicine.” Indeed, the program and the city both appeal to medical students throughout the U.S., who find that their offerings are different from what’s expected in the Northeast – from the pleasant clash of cultures to the level of educational excellence.


“Here, in our program, we’re situated at Penn Presbyterian, which is on the edge of the Penn campus, so we’re on the periphery – we’re surrounded on three sides by the community of West Philadelphia, but on one side, still connected to the Penn campus,” said Assistant Professor of Clinical Family Medicine and Community Health Margaret Baylson, MD, MPH. “That’s my cheesy metaphor for the type of educational experience we seek to give our residents. Very community-engaged, community-facing – we are a link for Penn to the West Philly community, but the quality of education on every single rotation is, I feel, second to none. “So we can allow residents to not have to choose between community or academic,” Baylson said. 18 | Keystone Physician | Spring 2017

“What I love about Philadelphia is the fact that it’s a diverse city,” said resident Claudia Castillo-Tussey. “Sure, there are certain pockets where people kind of tend to live, but everybody comes together in the center, in Center City. You have blue collar, white collar, and all colors of people in the city coming, and I think that’s very special about Philadelphia in contrast to some other bigger cities where everybody kind of remains in their own pockets or their own corners.”

“I went to medical school in the south, at Meharry Medical College in Tennessee, where family medicine is really a big part of the culture,” said resident Toni Aluko, MD. “When I was looking at residency programs, I wanted to come back to the Northeast, where my family is from, a lot of people discouraged me from going back to the northeast because they felt like family medicine wasn’t very big here – care was more segmented into internal medicine, OB-GYN, pediatrics. And growing up in Maryland, that was what I saw a lot too. “I found that Penn is totally the opposite,” she said/ “You get very robust training here.” The community-based approach, in addition to

the program’s broad scope, is a unique feature among residency programs. “I do think in addition to providing a niche in women’s health, obstetric care, reproductive health, we also attract residents who are really interested in community medicine in an urban setting,” said Baylson. “I remember when I was looking at residency programs, I was – as a family medicine applicant – I was looking for a program that was authentically engaged in the community, where I felt like I could really learn about that community and serve that community.” It’s a patient population whose health care needs are often secondary – or, in many cases, related – to their socioeconomic status.

“We don’t need to leave our office to be community medicine, because the patients we’re serving have so many needs that go beyond strict medicine. Sometimes you walk into the room and realize what the patient really needs is secure housing,” said Baylson. “You can talk to them about insulin and pills all you want, but their life is in total chaos because of X-Y-Z thing, so what they need might be more of a social worker, and that might be your job on that visit. So we teach that overtly, but also sort of subconsciously, because it comes up in so many office visits all the time. “The environment and pressures of urban life often lead to unhealthy behaviors,” she said. “This may not be unique to a city, it may just be America in general, but I think so many of our pa-

(L-R) Chief Resident Elizabeth Collins, MD; Ben Cocchiaro, MD; Claudia Castillo-Tussey, MD; Toni Aluko, MD.

Every week, Penn family medicine residents discuss the important items on their group agenda over coffee and bagels.

20 | Keystone Physician | Spring 2017 | 21


tients have a sedentary lifestyle and have not had role modeling in healthy eating, so patients come in behind the 8-ball in terms of healthy behaviors that are going to lead to good health outcomes. On the front lines of health care among an underserved community with such deep needs, care that goes far beyond the clinical turns into a very real type of activism. It’s a chicken-oregg question: does Penn Medicine draw socially conscious physicians, or does it make them? The answer is probably a bit from column A, a bit from column B – but these residents are concerned with so much more than a 15-minute office visit. “I think one of the things that drew me to this program initially was how socially conscious I found all of the attendings to be,” said Chief Resident Elisabeth Collins, MD. “A lot of them truly want to be integrated into the community and help the West Philadelphia population. When we’re on our community medicine rotation, we’re sort of all over Philadelphia at federally qualified health centers, at free clinics throughout the city, and you really do feel like you’re helping the city, even if it’s just for a couple months. “We have faculty who are incredibly socially conscious and engaged,” said resident Ben Cocchi22 | Keystone Physician | Spring 2017

aro, MD. “That allows us to have these wonderful discussions of what’s the role of the physician in the community. And it’s like, we are the natural advocates for the poor. We see everything. Last week, I took care of a patient who lost his toes to frostbite because he lived in an apartment that didn’t have heat or hot water – I thought that went out of style in the 1900s, but here we are in 2017, and it’s still an issue.

“Because we witness all of this, we have a duty to go out and talk about it and raise awareness about it and advocate for our patients,” he said. “That’s where a lot of that community medicine aspect comes in.” If you just focus on one organ system and forget that the person is living in an environment and in a house, in a neighborhood, with a budget or very little funding, you can miss the point,” said Baylson. “You know – ‘Why aren’t you just taking that pill? The pill is going to fix you.’ ‘Well, here’s the deal: there’s a copay on that pill, so think about prescribing a different one. Or recognize that it takes me three buses to get here, and that’s really hard. Or recognize that my neighbor’s house just burned down last week.’ “I think family doctors have that whole-person perspective,” she said. “The ones who are attracted to family medicine are the ones who really thrive when they are engaging the whole person and really seek to understand the environment that the patient’s coming from, because it allows them to overcome treatment barriers that they might not otherwise be able to.” That’s why Pennsylvania’s investment in the primary care workforce pipeline – and its funding of three additional residency slots in the Penn






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Family Medicine Residency Program – has been so crucial to the desperately needy patient population in West Philadelphia. “We’ve kind of doubled our community medicine exposure for all 27 residents, and we have a track within the program called the community medicine track,” said Baylson. “The residents in that track have two extra months spent in an FQHC (federally qualified health center), then mentorship for their elective time to also be in communitybased settings. “Our commitment to the community medicine rotations is pretty huge, because we always have a resident on the rotation and oftentimes two,” she said. “What that means is that we’ve committed to three free clinics to provide staffing 48 out of 52 weeks of the year. That’s really valuable to patients.” The sad reality in American health care is that, while investing in family medicine reimbursements and training is extremely cost-effective and promotes better patient outcomes, it’s not prioritized.

Margaret Baylson, MD, Assistant Professor of Clinical Family Medicine and Community Health, hosts a panel for Penn alum to discuss their medical careers. 24 | Keystone Physician | Spring 2017

“Our health care system nationally does not value and reimburse primary care in a way that produces more primary care physicians,” said Baylson. Even health systems that are doing vast amounts of residency training take a loss when they decide to train family medicine or internal medicine as opposed to, say, a GI fellow who’s going to do a million colonoscopies. The health care system in this country is set up to reimburse procedures, not cognitive medicine where you’re sitting in a room, talking to a patient, and helping to solve their health problems on the preventive, proactive side. “More and more, we’re realizing those are the doctors who are actually going to save money for the health care system if we prioritize things right,” she continued. “At this point in time, while we still don’t have the funding right on reimbursement to produce the outcomes that we’re looking for nationally in terms of health care savings, at least producing the primary care physicians who can go out there and do that work is so critical. Helping to support the residency training is really valuable.”

The weekly resident meetings sometimes include hands-on clinical training.

Family medicine deserves this investment.

“I think it can be challenging sometimes to step back and realize that these difficult patients might But the patients deserve it more. not be taking care of their diabetes, and that can be frustrating,” said Collins. “But when you think “I think that the way health care is set up now, it about what they’re dealing with in their day-tomakes it challenging to provide adequate, good day life, that they don’t have a grocery store or care – not necessarily to provide compassionate that they’re fighting for custody of their children, care,” said Collins. “But I think when you’re having or they don’t have a job, as long as you’re looking a 15-minute appointment and there’s someone at the bigger picture, you realize their diabetes is who’s having some sort of crisis on top of their the last thing on their mind. Maybe what we really chronic disease management, it’s difficult to do need to be doing is focusing on some of those all of that in 15 minutes and feel like you’ve really other social determinants of health that will help made a difference in their life.” them lead healthier, happier lives.” “Obesity, diabetes, hypertension, we see so much in our patients here. In terms of other unique challenges to the urban population, so many of our patients are surviving in social chaos – they don’t have housing security, have been evicted, unsafe homes, house fires,” said Baylson. “Unfortunately, crime is pretty real, and there are robberies – I just can’t tell you how many times I’ve heard my patients say “my medicine got stolen,” and that just has huge implications for health – if you don’t feel secure, and your environment doesn’t have some sense of stability.”

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To learn more about career opportunities at Patient First, contact Recruitment Coordinator Eleanor Dowdy at (804) 822-4478 or or visit | 25

Legal and Compliance Update CHARLES I. ARTZ, Esq, General Counsel

Complex chronic care management; new Medicare reimbursement rules; incident-to direct supervision exception Among the multitude of changes in the 1,402 pages of federal regulations implementing the 2017 Medicare Fee Schedule, new payment guidelines and incident to exceptions have been adopted for complex chronic care management services. Here is a brief summary of the new rules. The final regulations confirm that a separate payment will be made for CPT Codes 99487 and 99489, as follows: CPT Code 99487 – complex chronic care management services, with the following required elements: • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; • Chronic conditions that place the patient at significant risk of death, acute exacerbation and decompensation, or functional decline; • Establishment or a substantial revision of a comprehensive care plan; • Moderate or high complexity medical decision making; 26 | Keystone Physician | Spring 2017

• Sixty minutes of clinical staff time directed by a physician or otherwise qualified health care professional, per calendar month. CPT Code 99489 •

Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month (list separately in addition to code for primary procedure).

Several compliance points must be considered: 1. Less than 60 minutes of clinical staff time in the service period cannot be reported separately. 2. Less than 30 minutes in addition to the first 60 minutes of complex chronic care management in a service period cannot be reported. 3. The interpretive guidelines state that CMS requires 60 full minutes of service for

reporting CPT Code 99487 and 30 full additional minutes for each unit of CPT Code 99489. Accordingly, the mid-point rule relative to other Time Based codes does not apply. 4. CPT Codes 99487, 99489 and 99490 may only be reported once per service period (calendar month), and only by the single practitioner who assumes the care management role with the particular patient for the service period. In other words, a specific patient would be classified as eligible to receive either complex or noncomplex chronic care management services during a given service period, not both, and only one professional claim can be submitted for that service period by one practitioner.

tioner). The physician (or other practitioner) supervising the auxiliary personnel need not be the same physician (or other practitioner) who is treating the patient more broadly. However, only the supervising physician (or other practitioner) may bill Medicare for incident to services. 42 CFR §410.26 (b)(5) (emphasis added). The new regulations define general supervision as follows: General supervision means the service is furnished under the physician’s (or the practitioner’s) overall direction and control, but the physician’s (or the practitioner’s) presence is not required during the performance of the service. 42 CFR §410.26(a)(3).

5. Several chronic care management service elements for CPT Codes 99487, 99489 and 99490 are summarized in a Table prepared by CMS. A copy is attached for your review. Those three codes have different amounts of clinical staff service time provided; different complexity of medical decision making; and different care plan functions. CMS modified the incident to rule to accommodate physician and practitioner delegation of these services. The new regulation states as follows: In general, services and supplies must be furnished under the direct supervision of the physician (or other practitioner). Designated care management services can be furnished under general supervision of the physician (or other practitioner) when these services or supplies are provided incident to the services of a physician (or other practi-

The interpretive guidelines define designated care management services as CPT Codes 99487 and 99489 (discussed above) as well as a series of new G Codes relating to initial or subsequent psychiatric collaborative care management under G0502, G0503, G0504, G0507. For compliance purposes, please note that this is the only exception to the Medicare incident to rule direct supervision requirement. Designated Care Management Services require only general supervision (not direct on-premises supervision). Every other service requires the physician to provide direct on-premises supervision to bill it under the incident to rule. This is an isolated exception, and I hope it does not create any confusion with the physicians and extenders. Finally, auxiliary staff should document their start and stop times for the DCCS services throughout the month in order to justify the time-based code billing. | 27

Have you or a colleague done something worth bragging about? The PAFP wants to hear about you! In specific, we want you to tell us about your volunteer or military work, awards, accomplishments, things you’ve written and recorded, and more. Do you or a PAFP member colleague volunteer at a local clinic? Have you recently published a book? Did you receive any kind or special recognition or award this past year for your hard work and dedication to family medicine? Let us know – you could be a part of our PAFP Brag Board at the PAFP’s Harrisburg CME Conference in March 2017! Submissions are simple: just send us a short description of your accomplishment (For example, “This is the tenth year that Dr. Smith has served as a volunteer at the Anytown Free Clinic; Dr. Sue Suzie completed her military residency at Everyville Military Academy and now holds the rank of Commander in the U.S. Navy, stationed in Somewhereland, Pennsylvania.”) Send a submission for yourself or a colleague to

Please be sure to include your or the PAFP member’s name, current place of employment, and volunteer work or accomplishment. Submissions will be displayed proudly on the PAFP Brag Board during the Harrisburg CME Conference at the Harrisburg Hilton.

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The PAFP Mobile App The Pennsylvania Academy of Family Physicians is excited to announce the release of its mobile app, PAFP Connect, for iOS (iPhone, iPad) and Android (Samsung Galaxy, Google Nexus, Motorola Moto X, Amazon Kindle Fire) devices!

PAFP Connect was built exclusively for PAFP members to give you fast, convenient access to the PAFP, as well as to your peers. This app includes a mobile version of the PAFP Community - but not just that. In addition to being able to access your updates, activity feed, groups, and friends, PAFP Connect brings PAFP publications like Keystone Physician and Progress Notes straight to your smart phone or tablet. PAFP Connect also contains daily news and information that you need to know, from government affairs updates to CME information. You can even turn on notifications to alert you to breaking updates and events.

Available Now! Downloading the app is easy! Just search for PAFP Connect on your iPhone’s app store to get started. Alternatively, click on the icon for the app store that matches your device.

PAFP Connect was built in-house exclusively for PAFP members. To access the mobile app you will need to know your AAFP member ID number. For login assistance, email Michael Zigmund, PAFP’s Chief Communication Officer | 29

Legal and Compliance Update

Retroactive Denial of Reimbursements Act: Act 146 of 2016 On Nov. 4, 2016, Gov. Tom Wolf signed the Retroactive Denial of Reimbursements Act into law as Act 146 of 2016. Health care associations and organizations have been actively lobbying for this legislation for many years, and it is finally enacted. The Retroactive Denial of Reimbursements Act includes the following provisions: 1. Act 146 applies to commercial health insurance companies, which include PPOs, HMOs, traditional commercial insurers (such as Aetna, Cigna, United, etc.) and all of the Blue Cross and Blue Shield plans. 2. Act 146 does not apply to any Medicare, Medicaid or federal payers, and does not apply to any reimbursements made as part of an annual contracted reconciliation of a risk-sharing arrangement under an administrative services provider contract. It appears Act 146 would not apply to self-funded ERISA plans or risk-sharing contracts. Also, Act 146 does not apply to auto insurance or workers’ compensation claims. 3. Act 146 protects all licensed professional health care providers and facilities. 4. Commercial health insurance companies may not retroactively deny reimbursement as a result of an overpayment 30 | Keystone Physician | Spring 2017

determination more than 24 months after the date the insurer initially paid the health care provider. Act 146 does not define the term “deny.” It may be interpreted as the receipt of a demand letter from a commercial health insurer identifying an alleged overpayment and requesting a refund. For Highmark and other health plans that allow internal appeals before the overpayment is finalized, we will argue that the “denial” is not triggered until all internal appeals are exhausted such as the Highmark Medical Review Committee. 5. A commercial insurer that retroactively denies reimbursement to a health care provider shall do so based upon coding guidelines and policies in effect at the time the service subject to the retroactive denial was rendered. That means third-party payers cannot use coding guidelines and medical policies in effect at the time of the audit or the refund demand (which frequently occurs). Therefore, Act 146 prohibits retroactive application of coding guidelines and medical policies. 6. An insurer shall provide the health care provider with a written statement specifying the basis for the retroactive denial. 7. Six exceptions to the two-year retroactive

denial lookback limitation apply. The twoyear lookback limitation does not apply if: •

• • •

The information submitted to the insurer constitutes fraud, waste or abuse as defined by Act 146 (see below). The claim submitted to the insurer was a duplicate claim. The denial was required by a federal or state government plan. Services were subject to coordination of benefits with another insurer, the medical assistance program, or the Medicare program.

8. The first exception to the two-year lookback limitation is fraud. The term “fraud” is “any activity defined as an offense under 18 Pa.C.S. The term “fraud” is “any activity defined as an offense under 18 Pa.C.S. §4117,” which includes submitting false claims (i.e. claims containing a material misrepresentation of fact or a material omission); and a violation of the state AntiKickback statute. 9. The second exception to the two-year lookback limitation is waste. Act 146 defines waste as “the overutilization of professional medical services or the misuse of resources by a health care provider.” The concern with this exception is that claims denied based upon lack of medical necessity may fit within the “overutilization” component of the definition of “waste.” Act 146 does not separately define “overutilization.” 10. The third exception to the two-year lookback limitation is abuse. Act 146 defines abuse as “incidents or practices of providers, physicians or suppliers of services and equipment which are inconsistent with ac-

cepted sound, medical or fiscal practices.” 11. Exceptions applicable to duplicate claims or denials required by federal or state government plans are fairly obvious. 12. The final exception is for services subject to coordination of benefits; however, if an insurer retroactively denies reimbursement based upon coordination of benefits, providers have 12 months from the date of denial to submit a claim for reimbursement for the service to the correct payer, and a longer amount of time if the payer responsible for the payment permits a longer time period than 12 months. 13. Act 146 expressly allows any insurer to request medical or billing records in writing from a health care provider. Providers are obligated to submit the necessary records to the insurer within 60 days of the date of the request. 14. The period of time in which the health care provider is gathering the requested documentation is added to the 24-month lookback period. As a practical matter, however, this “tolling” clause (which adds the total number of days it takes for the provider to send in the records to the two-year lookback limitation) applies only if the insurer requests records before two years expires from the date the claim was paid. 15. Act 146 takes effect on Jan. 3, 2017. Because Act 146 focuses on insurance companies’ retroactive denial of payment, Act 146 arguably imposes the two-year lookback limitation for every refund demand issued after Jan. 3, 2017, not claims submitted after that date. | 31

Pennsylvania Academy of Family Physicians Foundation




Online CME = reward points PAFP members, collect 10 reward points and earn discounts at PAFP Foundation CME conferences or discounts off PAFP apparel. Your reward points will be added to your member record after you complete the webcast or monograph post-test and evaluation.

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Keystone Physician Magazine - Spring 2017  
Keystone Physician Magazine - Spring 2017