NEWS FROM NEPHO – Winter 2020


Gary Mendese, MD               
DermPhysicians of New England          
83 Herrick Street – Suite 3001
Beverly, MA 01915
(P) 781-272-7022       (F) 781-272-8786

Audrey Duva-Frissora, MD              
Beverly Radiological Associates
85 Herrick Street
Beverly, MA 01915
(P) 978-922-3000       (F) 978-927-3534


  • Betsy August, MD has joined Beth Israel Lahey Health.  Effective 4/6/2020, the practice will be renamed NMP OB-GYN Salem and relocating from 9 Colby Street Salem, MA 01970 to 84 Highland Ave. Suite 305  Salem, MA 01970.
  • Effective 2/13/2020, Maura Mc Grane, MD relocated from 83 Herrick Street Suite 2001 Beverly, MA to
    75 Herrick Street Suite 114 Beverly, MA 01915.


NP PA  MEETING – CME Approved    Click here for meeting flyer
Guest Speaker: Carol Freedman, RPh, MAS, BCGP
Date: March 17, 2020 @ 12:00 p.m. (Noon)
Place: 500 Cummings Center, Suite 6500
Good Harbor Room – Beverly, MA 01915
RSVP: Judith.O’ or 978-236-1739

Date: March 25, 2020 @5:30 p.m.
Place: 500 Cummings Center, Suite 6500
Good Harbor Conference Room – Beverly, MA 01915
RSVP: or 978-236-1784



March 10 @7:00 a.m.  │   March 26 @12:30 p.m.   │   March 30 @5:30 p.m.No Video Conf. at LOCD

Please note: the same presentation will be repeated at each of the three Open Meeting I sessions.
Attendance at more than one Open Meeting I meeting will NOT 
provide additional attendance credit

Primary Care Physicians and Specialty Physicians  will receive credit for March 2020 meetings
by attending an Open I meeting session.

Open Meeting I in March 2020 will replace March POD meetings

                                                                                All meetings will be held at
Beverly Hospital  Lecture Hall  │  Lahey Outpatient Clinic, Danvers (exception – 3/30) │ Addison Gilbert Hospital



Transitional Care Management (TCM) Coding

  • The background and benefits of TCM services, reimbursement examples, specifics of what constitutes interactive contact, face-to-face, and non-face-to-face visits was reviewed.
  • Additional information was provided on requirements for billing TCM services, including who may bill and the documentation required.
  • For additional information and details click here.


  • Carol Freedman shared key takeaways for the 2020 “Refined” Pharmacologic Algorithm from the ADA, which recognizes the cardiovascular benefits of SGLT2i and GLP-1RA agents independent of current A1c.
  • Therapeutic strategies to incorporate these findings were reviewed.
  • A cost chart reference for the newer diabetes therapeutic drug classes and insulin was shared.


  • Liz Isaac reviewed the details of and planning for the BCBS Patient Reported Outcome Depression measure, respiratory measures, and the BILH diabetes bundle measure.
  • The 2019 AQC year to date scorecard and comparison to last year was also reviewed.

Diabetes Care Collaborative Pilot

  • Dr. Joseph Peppe provided an update on the pilot, including the practices who will participate in the first phase and next steps.
  • Dr. Peppe thanked all practices who volunteered for the pilot.


  • Dr. Peppe reviewed the 2020 Attendance Policy changes.
  • There will be no POD or IPA meetings in March.
  • Dr. Peppe encouraged providers to attend the March Open Meetings which will be held in a different format than in previous years.
  • Information regarding the new (anticipated Biannual) Primary Care Quality Meeting for Office Managers and key quality contacts was shared. There will be 3 meetings, all with the same content, held at different locations.  Office Managers and practice colleagues who work on quality efforts are encouraged to attend.


Boston Medical Center Health Net Plan

Updated Administrative Appeals Policy: Provider Administrative Claim Appeals (0.5.019) Version 4

Boston Medical Center has posted the following: Document rewritten to reflect new one-level appeal process.  To view the complete policy, click here.

Harvard Pilgrim Health Care

Harvard Pilgrim has updated the payment policy for Evaluation and Management. To view the complete policy, click here.

Coming Soon: PCP Change Functionality in Portal

As part of our ongoing effort to deliver tools that make it even easier for providers to work with us, Harvard Pilgrim will soon launch a new feature that enables you to change a member’s PCP quickly and easily through our HPHConnect provider portal, with the member’s permission of course.

Read more

NIA 2020 Code Updates

As a reminder, Harvard Pilgrim has a partnership with National Imaging Associates, Inc. (NIA), to oversee prior authorization programs for certain services, including cardiac diagnostic tests and interventional procedures; diagnostic imaging; sleep studies; hip, knee, and shoulder surgery; spine surgery and cervical spine procedures; and outpatient interventional spine pain management services.

Read more

MassHealth Medical Diagnostic Prior Authorization Requirements

After issuing a proposal in November and retracting it following objections that MHA and hospitals raised, MassHealth has finalized its new prior authorization policy for certain medical diagnostic services. The revised proposal reduces the number of services subject to prior authorization from 381 to 162. Prior authorization is no longer required for most ultrasound services, radiation therapy, and arthroscopy – for at least the first year. MassHealth plans to revisit non-obstetric ultrasounds, radiation therapy, and arthroscopy a year from now and will include provider input in that decision-making process. MassHealth does not plan on requiring prior authorization for obstetric ultrasounds in the future.

In this latest version, six advanced imaging services were removed from the prior draft policy (CPT codes: 71552, 72159, 72198, 73225, 74263, and 76390.) These codes had been inadvertently included in the November policy; however, the codes are deemed non-payable in the acute outpatient hospital Subchapter 6 billing manual.

A transition phase of the policy will begin on March 1, 2020, when informational edits will be included on claims that do not have the required prior authorizations. Beginning June 1, 2020, claims will be denied if they do not have the required prior authorization approvals.

The prior authorization process for these services will be managed by a new MassHealth vendor called eviCore. The company offers further details on its website and will also hold web training sessions this month and in April. MHA expects additional details not outlined in the transmittal letter to be communicated through these forums and in upcoming communications from MassHealth and eviCore.

The policy will apply to Primary Care Clinician, fee-for-service, and Primary Care ACO enrollees. (These enrollees all receive services that are paid for directly by the MassHealth agency as opposed to Medicaid Managed Care Organizations.) The policy does not apply to inpatient and emergency department services. It appears that MassHealth Limited and the Health Safety Net are not affected by the policy.

MassHealth reports that the expected turnaround time for non-urgent prior authorization requests will be two days, and will be up to four hours for urgent cases. A retroactive request will also be permitted for up to 14 days following the date of service.

For prior authorization requests that are denied, a peer-to-peer review process will be available prior to a member having to file a formal appeal through the MassHealth Board of Hearings.

MHA is pleased that MassHealth reconsidered its proposal and reduced the number of services that will require prior authorization. We remain concerned, however, with the overall approach as it contradicts the MassHealth ACO program philosophy of holding providers accountable through risk arrangements and quality performance measures, and is duplicative of ACO efforts to control utilization of members. Prior authorization contributes to unnecessary administrative complexity, clinician burnout, and delays in patient care. MHA also remains concerned with how the MassHealth vendor eviCore will efficiently and appropriately work with providers. For these reasons, MHA plans to continue to advocate on these issues with MassHealth and other public policy makers.

For questions and comments on this policy, please contact MHA’s Dan McHale at or (781) 262-6044.

Tufts Health Public Plans

New Secure Provider Website

In the coming months, Tufts Health Provider Connect, the secure Provider website for Tufts Health Public Plans providers, will be replaced for Tufts Health Direct, Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans [ACPPs], and Tufts Health Unify by the secure Provider website currently used by Tufts Health Plan’s other lines of business (Commercial products [including Tufts Health Freedom Plan] and Senior Products).

Note: Data from the previous 12 months on Tufts Health Provider Connect will be available on the secure Provider website.

Any Tufts Health Public Plans provider that is not currently registered for the secure Provider website will need to register. Step-by-step instructions on how to register will be available on Tufts Health Plan’s public Provider website. Providers who are already registered do not need to take any additional action.

Providers and office staff can utilize the secure Provider website to view a member’s benefits or referrals, submit claims, and more. More information on this change will be made available prior to implementation.

Tufts Medicare Preferred

Dear Provider Partner,

As the early part of 2020 continues, you may hear from Medicare patients who missed the Annual Election Period or have already used their MA OEP.  As a result of the 2020 5-Star rating* given to the Tufts Medicare Preferred HMO plans by Medicare, your eligible patients have not missed the chance to evaluate their plan options.

What a 5-star rating means to Medicare-eligible beneficiaries:

  • They can enroll in the Tufts Medicare Preferred HMO plans all year long, not just during the Medicare annual election period (October 15 – December 7).
  • Continuous enrollment offers an opportunity to help those who struggle to afford the 20 percent cost share of medical costs on original Medicare
    • Struggle to afford the 20 percent cost share of medical costs on original Medicare
    • Are unhappy with their Medicare Advantage or Medicare Supplement plan
    • Have developed health problems and need a plan recognized for quality

If the patient is new to Medicare, or already on Medicare, they can enroll in a Tufts Health Plan Medicare Advantage plan for coverage beginning the first day of any month.

We ask that you make it easy for your patients to get information they need by:

  • Displaying plan materials, including 5-Star materials and the attached February & March meeting flyer, in common areas of your practice
  • Informing staff about the availability of monthly enrollment
  • Educating staff about the Medicare plans you accept

As a reminder, we also offer Tufts Medicare Preferred Supplement plans and, for participating providers, Tufts Health Plan Senior Care Options (SCO). Tufts Health Plan SCO (which also has a 5-Star rating) may be a great option for patients who are 65+ and on MassHealth Standard and continues to offer monthly enrollment.

If you have questions or need additional marketing materials for your practices, please contact me.


Marcel Philippe
Manager of Business Development
Senior Products Division
Tufts Health Plan
Cell: 617-417-2587
Office: 617-972-9400 Ext: 48010

*Medicare evaluates plans based on a 5-Star rating system.  Star ratings are calculated each year and may change from one year to the next.  Visit for more information.

                Click here to print the pdf




Each year, Boston Magazine partners with healthcare researcher Castle Connolly Medical Ltd. to create a definitive list of the best doctors in Boston, including hundreds of experts in fields such as dermatology, cardiology, orthopedics, pediatrics and more.

Boston Magazine

James A. MacLean
Allergy & Immunology
Asthma and Allergy Affiliates

Jeffrey Chang 
Lahey Hospital & Medical Center

Gregory R. Blaha 
Gurley Eye Care Associates


Jonathan S. Silver 
Cardiac Electrophysiology 
Lahey Cardiology, Beverly

James W. Hung
Ophthalmic Consultants of Boston

Benjamin A. Solky
Robert O’Brien Jr. M.D. & Associates, P.C.

Rita M. Sneeringer
Reproductive Endocrinology/Infertility
Cardone Reproductive Medicine and Infertility, LLC


Harvard Pilgrim Physician Group Honor Roll Announced 

Northeast PHO has been named to the 2020 Harvard Pilgrim Honor Roll.   Performance was measured in 16 measures across 3 clinical domains.   Northeast PHO providers exceeded the national Quality Compass 90th percentile in the Preventive Care domain which includes the following measures: breast and cervical cancer screenings, chlamydia screening in women, adolescent well visits, and well child visits in the third, fourth, fifth and sixth years of life.  Additionally, Northeast PHO providers exceeded the 75th percentile in Acute Care and Chronic Care Domains.  Click here to be directed to the HPHC Portal page.

Congratulations to all our practice colleagues!


Diabetes education program for providers with CMEs available

BILHPN has partnered with Alosa Health, a national non-profit organization based in Boston, to make available an educational program for providers focused on type 2 diabetes medications. The program is called “adviseRx” and is funded by the Massachusetts Health Policy Commission.

The goal of this program is to provide practitioners with up-to-date evidence-based treatment recommendations for type 2 diabetes, including individualized glycemic targets, choice of glucose-lowering medications based on cardiovascular outcomes data, and treatment simplification to avoid hypoglycemia.

NEPHO PCPs will be contacted by Alex Enriquez Zamalloa, a trained BILHPN pharmacist, who will meet with you in your office to review the materials, and will be available to serve as a resource for medication-related questions, devoid of all commercial influences. Participation in the program is completely voluntary.

After completing the educational module, you will be eligible to receive Continuing Medical Education credits.

We encourage you to participate in this CME program if contacted or if you are interested in participating in the “adviser” program, please contact Alex Enriques Zamolla at or Carol Freedman at

Practical Prescribing Pearls

See the Top-ten take-home points for the treatment of type 2 diabetes from the BILHPN Practical Prescribing Pearls program shared with NEPHO PCPs over the past several months.

For questions or more information contact Carol Freedman, NEPHO Pharmacy Manager at 978 236 1774 or


March is Colorectal Cancer Awareness Month

Statistics and risk factors

Excluding skin cancers, colorectal cancer (cancer that starts in the colon or rectum) is the third most commonly diagnosed cancer in both men and women in the United States. The American Cancer Society estimates 104,610 new cases of colon cancer and 43,340 new cases of rectal cancer in 2020.  It is expected that 53,200 people will die from this disease this year.

On average, the lifetime risk of developing colon cancer is about 1 in 23 (4.4%)  for men and 1 in 25 for women (4.1%).

The ACS recommends that people at average risk* of colorectal cancer start regular screening at age 45. The USPSTF recommends that adults begin screening at age 50 and continuing until age 75. This can be done either with a sensitive test that looks for signs of cancer in a person’s stool (a stool-based test), or with an exam that looks at the colon and rectum (a visual exam). These options are listed below.

People who are in good health and with a life expectancy of more than 10 years should continue regular colorectal cancer screening through the age of 75.

For people ages 76 through 85, the decision to be screened should be based on a person’s preferences, life expectancy, overall health, and prior screening history.

People over 85 should no longer get colorectal cancer screening.

*For screening, people are considered to be at average risk if they do not have:

  • A personal history of colorectal cancer or certain types of polyps
  • A family history of colorectal cancer
  • A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease)
  • A confirmed or suspected hereditary colorectal cancer syndrome, such as familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary non-polyposis colon cancer or HNPCC)
  • A personal history of getting radiation to the abdomen (belly) or pelvic area to treat a prior cancer

Types of screening chart

Please contact Lucia Kmiec, Health Coach if your office needs FIT tests at or 978-880-2318


OPTUM Newsletter – February  2020 Focus: Heart Disease

New 2020 CPT Updates And Changes Coming In 2021

Understanding the new 2020 Evaluation and Management (E/M) changes will help to optimize reimbursement within your practice. Changes are effective January 1, 2020.  CPT developed three new CPT codes for use by physicians, physician assistants and advanced practice nurse practitioners performing brief, online E/M services via a secure platform.

Online digital E/M Service

99421 Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes

99422            11—20 minutes
99423            21 or more minutes

These codes are for use when E/M services are performed, type that would be done face-to-face, are performed through a HIPAA compliant secure platform. These are for patient-initiated communications, and may be billed by clinicians who may independently bill an E/M service. They may not be used for work done by clinical staff or for clinicians who do not have E/M services in their scope of practice.

  • Report these services once during a 7-day period, for the cumulative time.
    “The seven-day period begins with the physician’s or other qualified health care professional’s (QHP) initial, personal review of the patient-generated inquiry. Physician’s or other QHP’s cumulative service time includes review of the initial inquiry, review of patient records or data pertinent to assessment of the patient’s problem, personal physician or other QHP interaction with clinical staff focused on the patient’s problem, development of management plans, including physician  or other QHP generation of prescriptions or ordering of tests, and subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent separately reported E/M service.”

  •  Other requirements: 
    • The interaction must be documented in the permanent record.
    • If within seven days of the initiation of the online service a face-to-face E/M service occurs, then the time of the online service or decision-making complexity may be used to select the E/M service, but this service may not be billed.
    • If the patient initiates this online service within seven days after an E/M service for the same problem, these codes may not be billed.
    • If the patient inquiry is within seven days of an E/M service for a new problem, the online service may be reported.
    • This is for established patients, per CPT®.
    • This may not be billed by surgeons during the global period.
    • The digital service must be provided via a HIPAA compliant platform, such as an electronic health record portal, secure email or other digital applications.
  • Additionally:
    • These services may only be reported once in a 7-day period.
    • Clinical staff time may not be included.
    • Don’t double count time with any other separately reported services, such as care management, INR monitoring, remote monitoring. (CPT book has a list of codes)

Blood pressure self-measurement: patient education, training, and analysis:

  • Two new CPT codes in 2020. The first is for patient education and calibration of a home blood pressure device
  • The second is for reviewing data collected by the patient at home, with a report and communication back to the patient
  • These join existing CPT codes for remote monitoring, but these are based on the patient’s self-measurement and reporting

99473: Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration

99474: separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient

Remote Physiologic Monitoring (RPM) has a new 20 minute code and allows remote care managers to bill an additional 20 minutes

99458, which pays for an additional 20 minutes of clinical care management time relating to vitals monitoring. This 99458 code is in addition to the existing CPT 99457 code for the first 20 minutes.

E/M Changes coming in 2021:

The changes are only impacting E&M codes 99201 through 99215. In particular, code 99201 is being eliminated entirely. Providers now will be allowed to select the level of service based on time or medical decision-making (MDM) only history and exams will still be documented, but they will not be considered in the selection of the level of service. There are several things you need to look at as you put together your preparation plan for the next year.

  • Understand the guidelines and what E&M codes will impact current workflow.
  • Updates will need to be made to electronic medical record (EMR) templates to support correct documentation.
  • Have an understanding of the financial impact to your practice by implementing these changes.
  • Practices will need to work directly with outside vendors to ensure a clear understanding of coding updates within the system they use.
  • Begin to think about a communication plan and establish a timetable for successful implementation.

NEPHO will be working to help prepare providers on new requirements.

Please reach out directly to Shawn Bromley at or 978-236-1704 if you have questions regarding the new 2020 E/M updates or would like to start reviewing changes that will need to take place at a practice level for the 2021 E/M coding changes.



Blackburn Primary Care – 1 Blackburn Drive

  • It is wonderful to be listened to and really discuss options for therapy and diagnosis. Superlative!

Cape Ann Medical Center – 1 Blackburn Drive

  • I am very happy to have Dr. Janet Doran as my provider.  She is truly excellent as is the rest of the staff.
  • Dr. Shawn Pawson is the best doctor I’ve ever had – his PA Josselyn is also great. I’ve recommended him to multiple friends and family members.

Danvers Family Doctors – 140 Commonwealth Avenue

  • Dr. Subroto Bhattacharya and Danvers Family Doctors are the best.  Dr. B. and the staff are amazing.

Lahey Primary Care, Beverly – 30 Tozer Road

  • I’ve always had a good positive experience with Dr. Tina Waugh. She listens!
  • Dr. Susan Deluca is thorough, thoughtful, knowledgeable, humorous, unhurried, professional,
    and congenial.

Lahey Primary Care, Beverly – 900 Cummings Center

  • Dr. Daniel McCullough and his team provide top notch healthcare. I have recommended this practice
    many times.

Lahey Primary Care, Beverly – 100 Cummings Center

  • Dr. Pierre Ezzi is a terrific provider. Knowledgeable and compassionate.

Lahey Primary Care, Danvers – 5 Federal Street

  • My experience has been that I have a “team” taking care of me!  Dr. Margaret Legner and all are great!
  • Dr. Steven Keenholtz provides an ALL around good experience. I’ve been seeing Dr. Keenholz for
    years and feel comfortable in his care.
  • Dr. Mauri Cohen and his staff always answer any questions completely and courteously.

Lahey Health Primary Care, Gloucester – 298 Washington Street 4th Floor

  • Dr. Victor Carabba is and has always been, very knowledgeable and caring when dealing with me.
    He takes the time to explain issues and test results in a way that is understandable for the patient.

Lahey Health Primary Care, Gloucester – 298 Washington Street 1st Floor

  • I am very happy with Dr. Amy Esdale. She cares!

Lahey Primary Care, Hamilton – 15 Railroad Avenue

  • I see Dr. Hugh Taylor or a member of his team – All excellent!

Lahey Primary Care, Manchester – 192 School Street

  • Dr. Nicholas Avgerinos is very professional and this practice is a caring group – I’m very satisfied with the care I’m given.
  • Very impressed with Dr. Jana Oettinger’s professionalism and manner. She obviously cares!

North Shore Pediatrics, Danvers – 480 Maple Street

  • Dr. Thomas Seman and his staff aren’t just our healthcare provider, they’re part of the fabric to our family. Thank you for taking such wonderful care of our kids!!!  We are forever grateful!!!
  • Dr. Shannon Dufresne is delightful to see!

North Shore Preventative HC, Beverly – 75 Herrick Street

  • This practice is outstanding and provides comprehensive and compassionate care at every visit.
    Thank you!

Thomas Pearce, MD, Gloucester – 279 E Main Street

  • Dr. Thomas Pearce makes me feel comfortable with any questions I may have.


The Northeast PHO recognizes colleagues who provide a positive experience for our patients, help us keep care local and meet our quality targets.

This month’s winners are:

Lisa Frost, Thomas Pearce, MD was recognized for her excellent patient outreach efforts to schedule needed appointments.

Laura Ellis, Northeast Eye Care was recognized for patient outreach efforts scheduling needed diabetic eye exam appointments.

Please let us know if you would like to nominate a team member in your practice or another practice for the recognition program.

We will deliver gift cards to the winners each month, and they will be announced here in the newsletter.

Look for the new winners in next month’s issue!

Deborah Orlando, practice manager – Lisa Frost and Dr. Thomas Pearce
Dr. Paul Greenfield and Laura Ellis