S.2849, vetoed on December 23rd, would have created a list of safeguards designed to protect patients with private, commercial health insurance plans seeking to remove drugs from their pharmacy benefit formularies, in the middle of a contract year. New York’s current law puts thousands of patients at risk of losing access to therapies for such chronic and life-threatening diseases as epilepsy, rheumatoid arthritis, multiple sclerosis, among many others. It also usurps decisions by physicians as to what the most effective therapy is to treat a patient’s condition. NYSSOS was in support of the passage of the bill.
The Governor vetoed the bill because of concerns that “Insurers would have to anticipate and set rates for hypothetical future drug price increases, causing higher premiums for everyone, while pharmaceutical companies would be able to raise their prices with impunity”.
On December 26, the Governor vetoed, S.6531, which would have increased the oversight, transparency and accountability of Pharmacy Benefit Managers (PBMS). According to a recent article published by MSSNY, the Governor vetoed the bill because of concerns that provisions could be pre-empted by ERISA, and invite scrutiny from the FTC and DOJ and “sweep in plans that are not true PBMs, but rather health benefit funds only.”
The NYS Workers’ Compensation Board has a number of resources to help medical providers understand and utilize the NY Workers’ Compensation Drug Formulary.
• Overview Video: Providers are encouraged to watch the Board’s video for medical providers, which includes a detailed overview, examples, and screenshots of the new drug formulary and the associated processes.
• Drug Formulary Web Page: Providers can also visit the Drug Formulary Overview page for information about the NY WC Formulary, a PDF of current and previous versions, details on the prior authorization process, frequently asked questions, and quick links to additional resources.
• New! January 13th Live Webinar Q&A Session: The Board is hosting a follow-up Q&A webinar so you can get answers to any remaining questions you may have. To make the most of this time, please be sure to watch the video and review the website information ahead of this session.
January 13, 2019 2:00 p.m. - 3:00 p.m. Register Here
If you would like to send your questions in advance of the session, or if you have an urgent question, please write to wcbmedicaldirectorsoffice@wcb.ny.gov.
My Glimpse into the World of Advocacy
Matthew Conti, MD
I didn’t know there is an underground subway connecting the House of Representatives and Senate buildings to the U.S. Capitol until I was running through the halls with Representative Virginia Foxx (R-N.C.). We jumped into the “members only” elevator, sprinted to the subway, and arrived just in time for a vote on the House floor. I also didn’t know there is an orthopaedic surgeon who is also a senator until I met John Barrasso, MD, FAAOS (R-Wyo.). I also didn’t know the difference between the terms “regulatory” and “legislative” until I did the AAOS Resident Advocacy Fellowship.
NYSSOS congratulates Dr. Conti on his advocacy efforts and for getting involved at the State level. We look forward to his participation on the State level as well!
> Read the full story
Over the past year, I have spent time meeting with and learning from the AAOS Office of Government Relations (OGR), located in Washington, D.C. Truthfully, before I applied for the fellowship, I didn’t even know that the office existed. Based on a recent poll undertaken during my AAOS Instagram stories takeover, about 70 percent of respondents said they did not know that AAOS has an office in Washington, D.C.
I have learned that effecting change in government requires persistence and patience. Ironically, one of the reasons I went into orthopaedics was that the care we provide has more immediate results. If a bone is broken, it needs to be urgently fixed. But if the government is broken, then we form a committee to debate the merits of fixing it, vote on a resolution, and then have a debate on the House floor.
Change does happen though—very slowly. We are fortunate as a profession to have dedicated, passionate people in Washington, D.C., fighting battles daily on behalf of orthopaedic surgeons—battles most of us do not even know about. While you’re preparing for your first total knee arthroplasty of the day, the AAOS advocacy team is fighting to make sure that case isn’t delayed because you couldn’t get timely prior authorization from the insurance company.
I’ve learned a tremendous amount over the past year. Prior to the AAOS Resident Advocacy Fellowship, I didn’t know that the voice of an orthopaedic surgeon in Congress is powerful, or how important it is to donate to the Orthopaedic Political Action Committee.
Matthew Conti, MD, is an AAOS 2019 Resident Advocacy Fellow and is completing postgraduate year-4 at the Hospital for Special Surgery
Read his full story: https://www5.aaos.org/aaosnow/2019/dec/advocacy/advocacy01/
Joanne Willer, Manager of coding and reimbursement resources in the AAOS Office of Government Relations, recently wrote an article for the AAOS Now summarizing the relevant changes to the musculoskeletal section for 2020.
To view her full article follow this link.
Below is a overview of her article. For a full summary of the additions, deletions, and revisions, refer to Appendix B of the CPT Manual.
Six new add-on codes describing insertion and removal of drug-delivery implant devices specific to musculoskeletal treatments have been added to the CPT code set for 2020.
The new codes were created to differentiate between the existing codes (which are in the integumentary section of CPT 11981–11983) and orthopaedic procedures for the treatment of soft tissue-, bone-, and joint-related infections. The new codes are for insertion, removal, and removal with reinsertion of nonbiodegradable drug-delivery implants.
Multiple specialties have been using the existing codes, which lack specificity, and that was the catalyst for change.
CPT code 20926, Tissue grafts, other (e.g., paratenon, fat, dermis), has been deleted for 2020.
That code was identified as potentially misvalued by the AMA Relative Value Scale Update Committee Relativity Assessment Workgroup (RAW). RAW determined that the code was being used for significantly different procedures, such as small soft-tissue grafts, correction of minor contour deformities, and placement into a defect for reconstructive purposes.
In the absence of code 20926, five new codes have been created to report those services.
Additionally, several changes were made to codes within the Extracranial Nerves, Peripheral Nerves, and Autonomic Nervous System section of the CPT Manual, including revised code descriptors to the 64400–64450 series of codes; instructional parenthetical notes; and deletion of codes 64402, 64410, and 64413.
The New York Workers’ Compensation Board Drug Formulary (NY WC Formulary) becomes effective on December 5, 2019 for all new prescriptions.
All new prescriptions for injured workers in New York State must be listed within the NY WC Formulary unless an alternative medication has been approved through the NYS Workers’ Compensation Board’s new prior authorization process.
The new electronic prior authorization process will soon be available through the Board’s Medical Portal; please watch for the notification.
Please visit the Board’s Drug Formulary Overview webpage for:
Information and resources related to requesting prior authorization through the Board’s Medical Portal, can be found on the Board’s Medical Portal Overview webpage.
For more information or assistance: http://www.wcb.ny.gov/content/main/hcpp/DrugFormulary/overview.jsp
The NYS WC Board is hosting webinars to provide training on the Drug Formulary and prescription prior authorization process. Visit the Board's website to register: http://www.wcb.ny.gov/webinars/
October 22, 8:30 a.m. - 9:30 a.m. October 24, 4:30 p.m. - 5:30 p.m. October 29, 8:30 a.m. - 9:30 a.m. ________________________________________ More Information For more information, visit wcb.ny.gov/content/ebiz/drugformulary/
General Formulary questions: WCBFormularyQuestions@wcb.ny.gov
Technical support questions: WCBCustomerSupport@wcb.ny.gov
Changes to National Government Services Local Coverage Determination Process In accordance with Section 4009 of H.R. 34-21st Century Cures Act (Public Law No: 114-255), CMS is updating the “Medicare Program Integrity Manual” with detailed changes to the LCD process.
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MLMIC’s The Albany Report offers policyholders a concise, insiders’ view of pending legislative, regulatory, and political developments that have an impact on the New York State medical malpractice insurance marketplace. Open or download the latest issue of The Albany Report: https://www.mlmic.com/why-mlmic/services-resources/albany-report
The State Legislature has concluded its 2019 Legislative Session. This was certainly one of the most memorable in recent years given the range of issues addressed following the democratic power-shifting election.
Be advised that we may be calling you to action during the summer to help secure vetoes from the Governor addressing the proliferation of e-scooters, e-bikes and unbalanced medical liability reforms. NYSSOS wishes to thank our members who took the time to make phone calls, write letters and personally meet with legislators on this year's advocacy program. Every interaction matters and we will continue to address the orthopaedic community's concerns in the coming year. We are very proud of this year’s interactive advocacy day with the most attendees we’ve had in the past few years as well as those who participated in the federal visits. We encourage you to reach out to your legislators and continue to build a relationship off session. You can always thank them for their efforts. You may also contribute to the ORTHOPAC which supports candidates who understand the current and long-term challenges that orthopaedists face when practicing in New York. At-A-Glance Orthopaedic Specific Issues • Defeat of inappropriate scope expansions by podiatrists, chiropractors and physical therapists • Defeat of efforts to impose a single payer system in NY • Defeat of several mandates related to opioid prescribing that would have imposed even more requirements on physicians prior to prescribing opioids • Defeat of numerous trial lawyer backed bills that would have: exponentially expanded awardable damages in wrongful death lawsuit; prohibited a defendant physician’s defense counsel from interviewing a medical malpractice plaintiff’s treating physician; and permitted the admissibility of certain “hearsay” statements of employees in civil actions. It should be noted that the Legislature did pass a couple of smaller measures opposed many groups that will affect certain cases involving multiple defendants and where an adverse judgment has been reached • Advancement of efforts to license athletic trainers • Passage of legislation to reduce insurer prior authorization (PA) requirements when a PA for a related procedure has already been received Highlights on the behalf of the House of Medicine • Enactment of legislation which ensures that medical contraindications are the only acceptable exception to vaccine requirements; • Legislation that curtails health insurers making mid-year changes to their prescription formularies; or increasing patient cost sharing; • Defeat of legislation which would have legalized adult use marijuana, as well as proposals that would have significantly expanded the medical marijuana program. Instead legislation was enacted that provides further “decriminalization” of small amounts of marijuana • Defeat of the authorization of retail health clinics
Advocating for the orthopaedic surgeon, patients and musculoskeletal health in New York.
info@nyssos.org 1-518-439-0000 Address: PO Box 38004, Albany, NY 12203
