Connection supplemental articles and policies–January 2015

Supplemental articles

Payment policies

These policies apply to Fallon Health and Fallon Total Care unless otherwise noted.

Revised policies – effective March 1, 2015:  
The following policies have been updated; details about the changes are indicated on the policies.

  • Autism Services Payment Policy – updated codes in the policy (Fallon Health only)
  • Clinical Trials Payment Policy – Updated discussion on Category B IDE devices
  • Hearing Aid and Hearing Aid Exam Payment Policy – Updated list of reimbursed codes (Fallon Health only)
  • Inpatient Medical Review and Payment Policy – Updated discussion about readmissions
  • Team Conferences and Telephone Services Payment Policy – updated discussion about telemedicine
  • Vaccine Payment Policy – Updated Addendum A

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Let’s connect

A Connection interview with Dr. Phil Bolduc

Lisa Price-Stevens Dr. BolducLisa Price-Stevens, M.D. (left), Medical Director, Fallon Total Caresm, recently interviewed Philip Bolduc, M.D. (right), a family medicine practitioner with expertise in chronic pain management and opioid treatment. Dr. Price-Stevens encourages you to call her with feedback at 1-508-368-6323.

Massachusetts is struggling with the devastating consequences of opioid misuse, abuse and addiction. From 2000 to 2012, the number of unintentional fatal opioid overdoses increased by 90%. In 2012, 668 residents died from unintentional opioid overdoses, a 10% increase over the previous year.1

Massachusetts is not alone. In 2013, the U.S. Department of Health and Human Services deemed prescription-opioid overdose deaths to be a national epidemic.2

Dr. Phil Bolduc, a Fallon Health provider and a practicing physician at the Family Health Center of Worcester, has taken on the challenges of treating chronic pain and teaching others about the protocols for opioid treatment.

Dr. P-S: Please tell me more about your training and how you came to have a passion for chronic pain management and opioid treatment.

Dr. Bolduc: I trained at the Lawrence Family Medicine Residency and did a fellowship in HIV medicine at University of California, San Diego. When I returned to Lawrence, many of my HIV patients were on Suboxone® (used to treat opiate addiction).

So, I did additional training in Suboxone treatment and chronic pain management and learned a lot “in the trenches” as many of my patients skirted the edges of both chronic pain and addiction. I always get additional insight from my wife, too, who is a palliative care physician.

Eventually, I developed a nationally recognized chronic pain and opioid protocol that we use in our practice today.

Dr. P-S: How do you decide if a patient needs opioid treatment for pain management and do you take a “step” approach?

Dr. Bolduc: In general, I recommend that providers take a very deliberate and step-wise approach, first doing a thorough evaluation into the source of pain and trying to fix the problem. They shouldn’t feel obligated to prescribe opioid at the first visit.

I also recommend reviewing prior records to see what has worked and to look for a history of aberrant behavior. A drug screen up front is advisable, and providers should consult the state’s Prescription Monitoring Program.

In my practice, we put all of this information together and decide if the risks of opioids are outweighed by the benefits for that patient. We make sure the patient is informed about the risks, and we then develop a treatment agreement.

Dr. P-S: How do you convince other practitioners to treat chronic pain with prescribing opioids when appropriate?

Dr. Bolduc: I turn to the language from the Massachusetts model policy on opioid prescribing that discusses our obligation as physicians to treat and alleviate pain and suffering. Sometimes, even in non-terminal non-malignant pain, opioid use may be required.

We have to walk that fine line between relieving suffering and not prescribing injudiciously (which can be the outright refusal to prescribe opioid under any circumstances.)

Dr. P-S: How do you keep patients safe in treatment and handle suspected abusers?

Dr. Bolduc: In our practice we use a risk-tiering system as a baseline approach. A patient starts at a high-risk level with weekly monitoring visits. As treatment goes on, if there are no aberrant behaviors (i.e., the patient adheres to drug screen/random pill counts, appointments and the treatment plan), he/she moves to a lower-risk level with monthly visits and quarterly drug screens/pill counts. If we suspect risk behavior emerging, then we’ll revert to increased surveillance.

We have other safety mechanisms around the patient agreement and in the informed consent. We also have guidance on titration and which opioids are useful in certain types of pain, such as neuropathic pain, and offer advice on the proper use of methadone and what tests should be monitored in its use, such as EKGs.

Dr. P-S: Do you have any last thoughts?

Dr. Bolduc: We covered many of the important issues. In closing, I’d like to note the benefit of having chronic pain nurses in the practice setting. They take some of the burden off of providers for the frequent visits, medication refills, pill counts and urine drug screens.

The nurses see the chronic pain that patients experience between provider visits and can bill these visits as code 99211, so they are self-supporting. This model may not be feasible at all practices but, wherever possible, I recommend it.

Dr. P-S: Thank you so much for sharing your expertise on this challenging, but important, topic.

Note: Fallon Health has many resources to help with management of chronic pain. To learn more, visit the Fallon Health provider resources on our website and the Fallon Total Care providers clinical guidelines section of the Fallon Total Care website.

1 Fatal Opioid-related Overdoses Among MA Residents, 2000-2013. Massachusetts Department of Public Health, March 2013. Available at: Accessed on June 5, 2014.
2 Addressing prescription drug abuse in the United States: current activities and future opportunities. U. S. Department of Health and Human Services, 2013. Available at: Accessed on
June 9, 2014.

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Have you checked for excluded entities and individuals recently?

The U.S. Health and Human Services Office of the Inspector General (HHS-OIG) excludes certain individuals and entities from participation in Medicare, Medicaid and the State Children’s Health Insurance Program (SCHIP), and all federal health care programs.*

The Centers for Medicare & Medicaid Services (CMS) and the OIG require that all organizations participating in a federal health care program—such as health plans, physician offices, hospitals or ancillary providers—check the HHS-OIG List of Excluded Individuals/Entities (LEIE) and the General Service Administration Systems for Award Management on a monthly basis to ensure that they are not employing or contracting with an excluded entity. These lists are updated monthly and can be found at the following links:

Why check monthly?

The Patient Protection and Affordable Care Act has expanded the use of civil monetary penalties and provides clarification that a health care organization that contracts (through employment or otherwise) with an excluded or terminated individual or entity is subject to civil fines and penalties. The standard for liability is whether the organization “knew or should have known” of the exclusion or termination.

Because CMS and the OIG clearly state that monthly updates are available with the above lists, your organization would be at risk if you were found to contract with an excluded entity that appeared on a list and you had failed to do the monthly check.

What is the penalty for employing or contracting with an excluded entity?

The penalty can be as much as $10,000 for each item or service furnished. There have been reports of organizations being fined upwards of $1,000,000 for one claim. Therefore, the benefit of checking these lists monthly far outweighs the risks of not doing so.

Where can I get more information?

More information on this requirement may be found in the Fallon Provider Manual in the chapter titled, “Key compliance and regulatory requirements for providers.”

* As defined in section 1128b(f) of the Social Security Act ( based on the authority contained in various sections of the Act, including sections 1128, 1128A and 1156).

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Program offers extra protection for Summit ElderCare® participants

Fallon Health has expanded its partnership with Healthsense, a provider of senior care solutions, to offer the eNeighbor® monitoring system to our Summit ElderCare participants at all of our PACE locations. We successfully piloted the program with targeted NaviCare members last year.

This free program equips members with a remote monitoring system that is installed in each resident’s home. The system monitors an individual’s movements to alert caregivers in the event of an emergency. There are no cameras, microphones, beepers or buzzers. The Healthsense technology also alerts the PACE care team about any significant changes in activities of daily life, such as sleep patterns, eating and toileting. Our goal in offering eNeighbor is to help our members live independently for as long as possible.

“Fallon is very proud of the high quality of care it delivers to its members and to seniors in particular,” said Sarika Aggarwal, M.D., Fallon’s Chief Medical Officer. “Using the Healthsense eNeighbor platform, Fallon will dramatically increase the identification of potentially catastrophic episodes and will allow us to more effectively coordinate care for our members.”

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Testing Wisely – Noninvasive Prenatal Testing (NIPT)

Choosing Wisely logoContinuing our “Testing Wisely” series, this month we are putting the spotlight on noninvasive prenatal testing recommendations from the Choosing Wisely® campaign.

As you may recall, Choosing Wisely is an initiative of the ABIM Foundation that aims to raise awareness about the overuse of certain tests and help physicians and their patients engage in conversations that will result in making effective care choices based on each patient’s individual situation.

The campaign has caught the attention of us here at Fallon Health, where our interest is in improving quality in a cost-effective way.

The Society for Maternal Fetal Medicine makes the following recommendation regarding noninvasive prenatal testing (NIPT) as part of the Choosing Wisely campaign:

Don’t offer noninvasive prenatal testing (NIPT) to low-risk patients or make irreversible decisions based on the results of this screening test.

NIPT has only been adequately evaluated in singleton pregnancies at high risk for chromosomal abnormalities (maternal age >35, positive screening, sonographic findings suggestive of aneuploidy, translocation carrier at increased risk for trisomy 13, 18 or 21, or prior pregnancy with a trisomy 13, 18 or 21). Its utility in low-risk pregnancies remains unclear.

False positive and false negative results occur with NIPT, particularly for trisomy 13 and 18. Any positive NIPT result should be confirmed with invasive diagnostic testing prior to a termination of pregnancy. If NIPT is performed, adequate pretest counseling must be provided to explain the benefits and limitations.

After a careful review of the utilization in our network during a recent year, we determined that our providers are overwhelmingly ordering NIPT within the above recommendations.

Interestingly, however, the ultrasound findings that were reported as justification for ordering NIPT for women with maternal age less than 35 were not necessarily indicative of Trisomy, so one wonders if the threshold for ordering these tests is set too high. Stepwise and judicious diagnostic testing such as Level II ultrasound for non-specific ultrasound findings may be an appropriate alternative in these cases prior to ordering NIPT.

To learn more about the Choosing Wisely campaign in Massachusetts visit

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Quality focus

Reporting fraud, waste and abuse

Fraud, waste and abuse affect everyone. Combating fraud, waste and abuse is essential to maintaining strong and affordable health care.

  • Fraud can be defined as an intentional misrepresentation that causes a victim to part with something of value, and is considered a criminal act.
  • Waste is generally categorized as an act that causes a company to pay unnecessarily for a service.
  • Abuse occurs when an individual or entity “works the system,” so as to be paid (or paid more) for a service to which he/she would not otherwise be entitled.

Fallon Health is committed to detecting, investigating and resolving instances of error, fraud, waste and abuse.

If you suspect fraud, waste or abuse, please be sure to report the activity to Velinda Brown, Fallon’s Director of Internal Audit, at 1-508-368-9016.

You also may call Fallon’s Compliance Hotline anonymously at

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MassHealth update

MassHealth providers

Federally required disclosure requirements

Fallon Health, a participating MassHealth managed care organization, is required by the Executive Office of Health and Human Services (EOHHS) to incorporate and apply all federal program integrity requirements into our participating provider agreements.

Federal regulations (42 CFR §§ 455.100–106) require the collection of information regarding business ownership and control, business transactions, and criminal convictions from provider applicants, participating providers, and from other parties associated with that provider.

Fallon is expected to obtain this information using the Federally Required Disclosure Form provided by EOHHS. This disclosure form must be completed prior to the execution and renewal of the provider contract and when there are business ownership changes. Fallon supplies more information online related to this requirement and the Federally Required Disclosure Form.

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Product spotlight

Health Connector Open Enrollment continues for subsidized plans

Open Enrollment has been in progress since November 15 for more than 400,000 people who had Health Connector plans or temporary Medicaid coverage during the last year. If those members want to maintain coverage into 2015 after their current programs expire, they need to submit new applications.

Those enrolled in Commonwealth Care will lose coverage on January 31 if they don’t file a new application. People with temporary MassHealth will lose coverage on a rolling basis, either on January 15, January 31 or February 15—and are being urged to apply for new coverage as soon as possible. Coverage for those in a Health Connector Qualified Health Plan who do not need subsidized insurance, ended December 31.

Fallon offers Community Care
Fallon Health was chosen by the Massachusetts Health Connector Board to be one of five ConnectorCare plans* offered in Central Massachusetts in 2015. We introduced Community Care during this open enrollment period.

Community Care is a limited-network option for residents of Central Massachusetts who are looking for affordability, ease of use and trusted local providers. In addition to Reliant Medical Group and Harrington HealthCare, the Community Care network** is supplemented with selected additional providers: Saint Vincent Hospital; Harrington, HealthAlliance, Clinton and Marlborough community hospitals; UMass Memorial for tertiary care (with prior authorization only); and additional affiliated physicians—UMass Memorial and Health Alliance specialists.

For more information
Your patients who are interested may call us today to make an appointment with a Fallon Health enrollment assister at a location convenient for them. Call 1-508-368-9709.

Learn more by calling the Provider Relations Department at
1-866-275-3247, option 4.

* ConnectorCare plans have lower monthly premiums and lower out-of-pocket costs. Individuals or families living in Massachusetts with incomes at or below 300% of the federal poverty level (FPL) may qualify for ConnectorCare. Those with incomes above 300% FPL may still be eligible for subsidies to reduce the cost of insurance. They cannot be eligible for Medicare, MassHealth (Medicaid) or other public health insurance programs. Children under the age of 18 are not eligible for ConnectorCare plans, and would instead enroll in MassHealth.

** Community Care provides access to a network that is smaller than Select Care. In this plan, members have access to network benefits only from the providers in Community Care. Please consult the Find a Doctor tool at, or the Community Care provider directory—a paper copy can be requested by calling our Customer Service Department at 1-800-868-5200—to determine which providers are included in Community Care.

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