DeWITT, N.Y. — One of the criteria that Excellus BlueCross BlueShield (Excellus BCBS) used in selecting MDLIVE as the technology platform for its telehealth benefit was the ability to offer participation to local physicians.

“So MDLIVE is an open network and local physicians have the opportunity to go through the credentialing process and to become a participating provider with MDLIVE, which we thought was important relative to our local physician community,” said James Reed, regional president of Excellus BCBS.

Representatives from MDLIVE are speaking with local physicians about the opportunity to join that network, he added. Reed talked to reporters during a Nov. 29 news conference at the Excellus office in DeWitt.

Rochester–based Excellus is Central New York’s largest health insurer.

MDLIVE is a Sunrise, Florida–based “telehealth provider of online and on-demand health-care delivery services.”

All of MDLIVE’s doctors are board certified and licensed in the state of New York, said Leslie Courtney, senior VP of MDLIVE.

“MDLIVE providers cover the entire country, however, so if one of your members is out of state, vacationing, traveling on business … they would be allowed access to a doctor that’s licensed in that state in which they are at the time of the visit,” said Courtney in response to reporter’s question at the press conference.

She also provided a demonstration of the web portal, which is available for members through the website of Excellus BlueCross BlueShield.

“It’ll be a service available beginning in 2017 through our website,” said Reed. 

Members can either take the next available doctor-on-call or they can choose from one of the providers that are listed with availability within the network, said Courtney.

“…and the choosing option allows them to schedule a specific time of day,” she added.

The MDLIVE doctors go through a “rigorous” credentialing process, according to Courtney. It is accredited through the National Committee for Quality Assurance (NCQA) for its credentialing process, she added.

Washington, D.C.–based NCQA is a nonprofit that on its website indicates “organizations incorporating the seal into advertising and marketing materials must first pass a rigorous, comprehensive review and must annually report on their performance.” 

“[Our doctors] are throughout the country. They’re in each state … Some of them are working in a brick-and-mortar clinical setting. Some of them are working out of their home offices at the time of the visit,” said Courtney.

Dr. Richard Lockwood, VP and chief medical officer of Excellus BCBS’s Central New York region, said the health insurer has been introducing MDLIVE to local doctors and admitted “yes, there has been some pushback.”

“We’re trying to educate them on what the service is about. It’s not to take away from them, but to increase availability, accessibility, timeliness of visits that they may not always be able to provide,” said Lockwood in answering a reporter’s question during the Nov. 29 news conference.

Relying on data from the New York State Department of Health labeled “potentially preventable” emergency-room visits, Excellus  reported earlier this year that 10 common conditions account for more than 2 million annual visits to hospital emergency rooms statewide, and nine out of 10 of those could have been avoided or treated elsewhere. 

Of 6.4 million emergency-room (ER) visits in 2013, more than 2 million were for common conditions, such as ear or sinus infections and sore throats.

“When 2 million visits are for these 10 common conditions going to the ER, they weren’t going to their primary-care physician, so we’re giving people an alternative,” said Lockwood.  

Contact Reinhardt at ereinhardt@cnybj.com

LOWVILLE, N.Y. — The federal Centers for Medicare and Medicaid Services (CMS) has changed a funding formula and is pursuing millions in retroactive payments from some New York hospitals benefiting from two federal programs.

That’s according to U.S. Senator Charles Schumer (D–N.Y.), who said he’d fight attempts to “claw back critical” federal funds that allow small hospitals, such as those in the North Country, to provide “necessary” services to senior citizens and “underserved” populations in rural areas.

Schumer outlined his concern during a visit to Lewis County General Hospital (LCGH) in Lowville on Dec. 2.

The programs
Schumer explained that Sole Community Hospitals (SCH) and Medicare-Dependent Hospitals (MDH) are often the “only sources” of emergency care for miles in rural areas.

SCH and MDH are federal programs that provide hospitals, particularly in rural areas, with funding they need to continue “essential” health-care services in communities “that would otherwise not have options,” Schumer explained in a news release.

At the same time, they often “suffer” from declining patient volumes.

As a result, CMS provides these hospitals with the funding “needed to stay afloat.”

Formula change
CMS recently decided to change a calculation used to determine certain funding for SCHs and MDHs, according to Schumer.

When these hospitals have a decrease in discharges of more than 5 percent from one cost reporting year to the next, they can apply for a volume-decrease adjustment (VDA) payment.

Schumer explained that, “due to this circumstance beyond their control,” the federal government provides the adjustment payment to cover some of the costs needed to maintain necessary core staff and services.

However, Schumer said CMS has decided to “go after” hospitals to try and retroactively recoup funds based on the new formula and not the formula in place when it made these funding determinations.

The retroactive recalculations affect 16 New York facilities in the SCH and MDH with repayments that could total between $15 million and $20 million.

Lewis County General Hospital, for example, will soon receive a notice that it owes hundreds of thousands of dollars and will have only 15 days to pay.

LCGH estimates this amount will be “at minimum” $300,000, Schumer’s office said.

In addition, many other North Country hospitals are facing the same situation.

Massena Memorial Hospital; Carthage Area Hospital; EJ Noble Hospital (now Gouverneur Hospital); Champlain Valley Physicians Hospital; Adirondack Medical Center; and Claxton-Hepburn Medical Center in Ogdensburg are all part of this group of 16 New York SCHs and MDHs that could have to turn over “hundreds of thousands” of dollars each.

For example, Massena Memorial Hospital was recently notified it had to pay back $1.6 million to the Feds.

“These hospitals serve a vital public need, but are often under serious financial pressure because they serve fewer patients than their urban and suburban counterparts and receive a high percentage of Medicare beneficiaries,” Schumer said in the release. “They deserve our support in their continuous efforts to provide the highest level of care to residents. That’s exactly why I’m demanding CMS immediately reverse course on its attempts to claw back the federal funding it provided to these hospitals years ago so they could stay afloat and ensure critical healthcare access for rural communities and seniors. CMS should not come after these funds, after the fact. So I’m going to be fighting for tooth and nail for the justice our hospitals deserve just as our upstate hospitals fight for their patients every day.”

Additional reaction
Michele Prince, interim CEO of Lewis County General Hospital, and officials from other affected North Country hospitals, joined Schumer as he spoke.

“Lewis County General Hospital (LCGH) is one of the hospitals that will be affected by the Medicare low volume cuts. The funds, which are intended to provide support for safety net hospitals, like LCGH, will have a major impact for rural hospitals in the North Country,” Prince said in Schumer’s release. “If the Centers for Medicare and Medicaid Services proceeds with its plan to recoup funds that have already been utilized to serve patients, LCGH could potentially lose over $300,000. This burden on our facility and the other safety net hospitals would be significant.”

Prince said she hopes that CMS “will reconsider the retroactive payment.”

Schumer contends it is “completely unfair,” and is “demanding CMS immediately reverse course on this action…”                  

Contact Reinhardt at ereinhardt@cnybj.com