F e b r u a r y 2 0 11
Gartner Plastic Surgery and Laser Center
Utilizing the Latest Technologies to Optimize Results While Minimizing Scarring, Pain and the Need for General Anesthesia
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• Weinberg-Vitale Bill to Strengthen NJ Public Health Council Approved in Senate • New Jersey Receives a Waiver to Carry Out Health Law • How Reimbursements for Over-TheCounter Medications Will Affect Physicians • Medicare Financial Incentives are Available-Do You Qualify?
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Welcome to the February edition of New Jersey Physician, providing critical information
Publisher and Managing Editor Iris Goldberg
to the state’s medical community. Photographer Ken Alswang, At Home Studios
General anesthesia is a problem for some patients. Some health issues make elective surgical procedures dangerous for patients, others have significant fears related to being “put under”. Dr. Michael Gartner offers these patients the ability to have elective surgeries under local anesthesia, giving them a pain free procedure without the fear or danger associated with the more common methods commonly used. Breast augmentation and reconstruction, tummy tucks, liposuction and face lifts may now be done with mild sedation combined with an innovative use of local medication. His
Contributing Writers Iris Goldberg Christopher Monaco Robert Pear, Frank Ciesla Deidre Hartmann, CPA Mark Manigan, Esq. Debra Lienhardt, Esq Michael Schoppmann, Esq
the most innovative techniques to minimize or eliminate visible scarring.
New Jersey Physician is published monthly by Montdor Medical Media, LLC., 22 Burnet Hill Road Livingston New Jersey 07039 Tel: 973.994.0068 Fax: 973.994.2063
The Obama administration has granted broad waivers to four states including New
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Physician, please contact Iris Goldberg at
provide under the new federal health care bill. This will result in some patients having
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innovative practice also specializes in the use of fat grafting for such procedures as breast enhancement and “Brazilian butt lifts, giving a more natural result. He also uses
less than the minimum required coverage for essential benefits like hospital care,
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The New Jersey Assembly Health and Senior Services Committee unanimously
Although every precaution is taken to ensure
approved a bill that would improve the authorization and prompt payment requirements
accuracy of published materials, New Jersey
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Physician cannot be held responsible for opinions
procedures are now classified as covered benefits and would prohibit carriers from remitting payments to hospitals at a rate lower than the contracted rate. The 2012 Federal budget proposed by the Obama Administration delays the threatened 28% cut in Medicare payments to doctors for two more years, until after the elections.
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Contents
COVER STORY
4 February
Gartner Plastic Surgery and Laser Center
PHOTO BY Ken Alswang, At Home Studios
2 0 11
16
Food for Thought
Tabor Road Tavern
18
CONTENTS Legal Issues
How Reimbursements for Over-The-Counter Medications Will Affect Physicians
patients are now subject to new rules governing reimbursement of the cost of certain over-thecounter (OTC) medications.
9 Marketing The importance of marketing your specialty practice
10 Statehouse 13 STATLaw 14 Finance Do you qualify for available Medicare financial incentives?
16 Food for Thought Tabor Road Tavern
18 Over-the-Counter Medications Reimbursement How will it affect physicians?
2
New Jersey Physician
Call for Nominations
New Jersey Physician Magazine invites all medical practices to submit nominations for cover stories. Practices should include a brief description of what makes the practice special. Please contact Iris Goldberg at igoldberg@NJPhysician.Org Februar y 2011
3
Cover Story
Gartner Plastic Surgery & Laser Center
Utilizing the Latest Technologies to Optimize Results While Minimizing Scarring, Pain and the Need for General Anesthesia By Iris Goldberg
Most people would like to change something about their appearance. Some flaws are minor and more noticeable to the individual in question than to others. Some are quite significant and whether as a result of illness, injury or genetics have a profound affect on the quality of one’s life. Whatever the case, more and more of us are opting to undergo cosmetic or reconstructive surgery in order to improve the way we look and to maximize a positive self-image. When planning for an elective procedure patients and/or referring physicians should thoroughly investigate the options available to them in terms of choosing a surgeon and
An overview of the procedures performed by Dr. Gartner includes the following:
• Breast Reconstruction • Scar-less Breast Augmentation • Scar-less Breast Reduction • Vertical Breast Reduction and Lift • Scar-less Breast Lift • Body Lift After Gastric Bypass Surgery • Tummy Tuck • Liposuction • SmartLipo™ (Using laser light technology) • Brazilian Butt Lift • Labiaplasty • Sclerotherapy • Mesotherapy also evaluating the facility in which he or she operates. Patients need to be assured of the surgeon’s skill and beyond that of their safety and comfort throughout the entire surgical experience. With office locations in Paramus and Eatontown, Michael Gartner, DO, FACS has created the Gartner Plastic Surgery & Laser Center with the goal of providing patients with beautiful results while using the most innovative techniques to minimize or even eliminate visible scarring, lessen pain and avoid the use of general anesthesia for some procedures. In his stateof-the-art surgery center, Dr. Gartner makes the comfort and safety of his patients his top priority.
p Dr. Michael Gartner created the Gartner Plastic Surgery & Laser Center to provide patients with beautiful results while using the most innovative techniques to minimize or eliminate scarring, lessen pain and avoid the use of general anesthesia for some procedures.
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New Jersey Physician
For those procedures that require a hospital stay or are covered by insurance plans that consider ambulatory surgery centers to be out of network, Dr. Gartner is affiliated with both Valley Hospital and Monmouth Medical Center. He does anticipate that the Gartner Plastic Surgery & Laser Center will attain in-network
• MACS (minimal access cranial suspension) Lift • Short Scar face Lift • Rhinoplasty • Eyelid & Eyebrow Lift • Blepharoplasty • Otoplasty • Cheek/Chin/Lip Augmentation & Facial Implants • Neck Liposuction • Mole Excision • Injectable Fillers • Facial peels
status from many insurance plans in the not too distant future. Patients are seen by Dr. Gartner to undergo cosmetic procedures for virtually every part of the body. What sets him apart from some other plastic surgeons is his determination to investigate ways to improve upon traditional techniques in order to achieve the most pleasing result for each individual patient. For example, Dr. Gartner has mastered the cosmetic surgery
p Post mastectomy patients wear an external expander called the Brava bra prior to breast reconstruction with fat grafting.
techniques necessary to perform a “scar-less” procedure in many cases. Also, Dr. Gartner feels strongly about taking steps to effectively control pain during and after surgery. One exciting newer technique that Dr. Gartner offers for patients who have undergone mastectomy is breast reconstruction with fat grafting. This innovative procedure is presently being done by only a small minority of plastic surgeons but offers some significant benefits for appropriate patients. “This procedure suits patients who do not wish to have implants or may not want the morbidity of some of the other techniques such as a tram flap, deep flap or free flap,” explains Dr. Gartner. He is referring to the fact that these procedures involve extensive surgery with general anesthesia, muscle trauma and scarring. “I think this is a good alternative option for those women who fear traditional reconstruction,” Dr. Gartner adds. In order to undergo breast reconstruction with fat grafting after mastectomy, the patient first wears an external expander called a Brava bra for about ten hours a day (usually while sleeping). This comfortable soft gellike bra gradually expands the skin from the outside, creating an edema-like breast mound through the expansion of nerves and tissues. After approximately two months Dr. Gartner performs minimally-invasive liposuction to remove fat from an area of the body that has enough to spare, such as the belly, flank or
p Fat is collected and placed into syringes for reinjection.
thighs and meticulously injects this fat into the breast site that has been enlarged by the Brava expansion. After this procedure, the patient can usually resume normal activity within a few days. The transferred fat survives within the matrix of tissue that has been created by the Brava. The breasts are restored naturally as this procedure is repeated three times on average over the course of several months. If the breast has been radiated, the process can take up to five sessions. The patient receives the added bonus of gaining a more sculpted body as excess fat is removed from certain areas. (Of course patients who do not have adequate fat to spare would not be suitable candidates).
The “new” breast looks and feels like the patient’s own but contains no breast tissue to be concerned about and no foreign bodies. Best of all, the newly constructed breast retains a more normal sensation. If the healthy breast is much larger or droopier than the reconstructed breast, Dr. Gartner can reduce and/or lift the other breast in order to achieve symmetry. It is important to note that although reconstruction after mastectomy is covered by health insurance, liposuction usually is not. Dr. Gartner is currently involved in pursuing proper channels to determine if the present restrictions can be lifted to allow coverage for the fat grafting procedure and he is hopeful that in time this will become an insurance-accepted alternative to traditional breast reconstruction methods. For non-cancer patients who simply want larger breasts, insurance is not an issue. Dr. Gartner can use the fat grafting method to increase breast size for these women and that process would require only one session since the patients already have breasts to build upon. Generally, breasts could be increased by one to one and a half cup sizes.
p Dr. Gartner performs minimally invasive liposuction to remove fat from an area of the body that has enough to spare.
Fat grafting has actually been used by Dr. Gartner for years to enhance the buttocks. During this procedure, which has recently been termed the Brazilian butt lift, fat is harvested from other parts of the body via standard minimally-invasive liposuction techniques and then transferred to the buttocks. The result is buttocks that are firmer and smoother than they were and other parts of the body (most Februar y 2011
5
with this technology enables him to teach other surgeons how to become proficient with it as well. Dr. Gartner inserts a very small cannula containing a laser fiber into the skin. The cannula is moved back and forth delivering the laser’s energy to the fat cells, causing them to rupture and easily drain away. SmartLipo™ is a minimally invasive procedure and can be performed under local anesthesia. The laser causes blood vessels to coagulate immediately on contact, resulting in less bleeding, swelling and bruising.
p Dr. Gartner has been using fat grafting for years to enhance the buttocks. During the Brazilian butt lift, fat is harvested from other parts of the body and transferred to the buttocks. The result is buttocks that are firmer and smoother than they were.
commonly the abdomen, waist, back and thighs) attain a more sculpted appearance.
traditional breast augmentation, Dr. Gartner is highly skilled in these procedures as well.
Another innovative procedure to enhance breast size that Dr. Gartner has perfected is scarless breast augmentation. Minimal incisions are made in the navel to ensure that scarring is barely if at all visible after recovery. Dr. Gartner then inserts saline breast implants through the navel. With this method, patients report little or no pain, no loss of nipple sensation and a speedy recovery. For patients who prefer
Dr. Gartner also offers women a scar-less breast reduction involving the latest surgical techniques that include liposuction of the breast tissue to reduce size. This method greatly reduces scarring and recovery time. For men with gynecomastia caused by excess glandular tissue and fat, Dr. Gartner employs a scar-less reduction technique that is specifically designed for men. This procedure is also associated with little or no scarring, fast recovery and minimal pain.
Although a number of cosmetic procedures are routinely performed with local anesthesia, many of the most popular procedures have traditionally required that the patient receive general anesthesia. However, for some patients, anesthesia is not a good option because of health problems that increase risk. Others are fearful of being put to sleep and won’t consider an elective procedure that requires general anesthesia. Still others experience intractable nausea as a result of anesthesia, even with premedication. Dr. Gartner is able to accommodate many suitable patients by performing some cosmetic procedures painlessly with local anesthesia
Besides offering patients minimal or no scarring for the more extensive cosmetic procedures, Dr. Gartner also excises moles, lipomas and other growths, skillfully using techniques that leave the skin virtually unblemished. This is especially important to patients who are having excisions on the face and other parts of the body that are exposed. Dr. Gartner shares that he sees many individuals who want to be assured that an excision will not leave an unsightly scar.
p SmartLipo™ is the most advanced technology available today for body contouring body sculpting and/or liposuction for the neck, arms, abdomen, thighs and knees.
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New Jersey Physician
A great many patients come to the Gartner Plastic Surgery & Laser Center requesting body contouring, body sculpting and/or liposuction for the neck, arms, abdomen, hips, thighs and knees. SmartLipo™ is the most advanced technology available today to perform these procedures and removes fat more evenly and precisely than traditional liposuction. Dr. Gartner’s considerable skill and experience
p Dr. Gartner is shown injecting local anesthetic prior to SmartLipo™.
and his wonderful staff made me feel so comfortable and secure,” she wants to share. “If I could be aware and have no pain and know this is a good thing that I’m doing – that’s my option,” Grace states. “Also, I picked the right doctor,” she emphatically adds. “Dr. Gartner is a sweetheart! Nothing is a silly question for him. He wants to know his patient’s concerns and he really makes you feel great,” Grace says with delight.
p Before and after breast augmentation. For some patients, Dr. Gartner can perform this procedure with local anesthesia and oral sedation.
along with an oral sedative. The “awake” breast augmentation and the “awake” face lift are examples of procedures that Dr. Gartner offers. Some of these surgeries can also be performed by Dr. Gartner without any oral sedation if this is what the patient prefers. Another advantage of this method for some, especially when affordability is an issue, is that the significant cost of anesthesia is deducted from the total price of the procedure. The key to the success of these “awake” procedures is the use of pre-emptive anesthesia. Dr. Gartner has learned through scientific research and while performing his own procedures, that if a local anesthetic is injected into the skin and the muscle area a few minutes before the incision is made, the patient will have considerably less pain after the procedure is completed. As a result, Dr. Gartner routinely uses pre-emptive anesthesia for his breast augmentations. Recovery room nurses have consistently reported to Dr. Gartner that his patients who received pre-emptive anesthesia had significantly less pain upon awakening. Anesthesiologists have also shared that these patients generally require less anesthesia and wake up feeling more comfortable than others. It was for this reason that a couple of years ago, when a patient came to see him for breast augmentation and shared her tremendous fear of being put to sleep, that Dr. Gartner agreed to perform her hour-long procedure with preemptive local anesthesia and oral sedation.
Since that time he has done many others in the same manner. “After each and every one of these I ask the patient if she would do it without general anesthesia again and without exception they all have said they definitely would,” Dr. Gartner reports. “Leslie” is one of Dr. Gartner’s patients who underwent “awake” breast augmentation not too long ago. She is someone who does not do well with general anesthesia. “I get extremely nauseous,” Leslie shares. In fact, she remembers being ill for days afterwards. When asked how it felt to be awake for her breast augmentation Leslie responds, “It was the most comfortable procedure I’ve ever had!” Dr. Gartner and his staff were so terrific,” she adds. “I felt no pain at all and the next day I was up and cooking breakfast,” Leslie happily reports. Most importantly, Leslie is thrilled with her new breasts. Although she really wanted the augmentation, Leslie confides that she might not have gone ahead if general anesthesia was involved. “But I would definitely do this again,” she emphatically states. At 54, “Grace” had wanted to have her breasts made larger for many years. When the opportunity finally presented itself, Grace opted to be awake during her implant procedure. She had heard about people who had adverse reactions to general anesthesia and also she didn’t like the idea of being put to sleep. “I like to be aware of what’s going on,” Grace admits. “This was the simplest procedure I’ve ever gone through,” raves Grace. “Dr. Gartner
In fact, the “awake” procedures have been so successful that Dr. Gartner now performs an “awake” breast augmentation with lift and a mini-tummy tuck during a three hour procedure that is performed under local anesthesia. He explains that with any of the procedures done with the patient being awake, while there is no real pain, patients may feel slight pulling, tugging or similar sensations while Dr. Gartner is working. More recently, Dr. Gartner has expanded his “awake” procedures to include face lifts for appropriate patients. He shares the case of a patient who was absolutely terrified of having general anesthesia. Somehow she learned that Dr. Gartner performed some cosmetic procedures with local anesthesia and came to see him, not too long ago, with a request that he perform a face lift for her without putting her to sleep. He felt confident that in her case the procedure could be safely and successfully completed without the need for general anesthesia. He is happy to report that all went well and the patient was delighted with the experience and the results. For some older patients, especially, general anesthesia could present a problem. While they might be cleared for anesthesia with surgery for emergent, life-threatening conditions, many internists and/or cardiologists could hesitate to approve anesthesia for a totally elective cosmetic procedure. Some of these patients would, however, have medical clearance to undergo a face lift that does not entail general anesthesia. For them, Dr. Gartner offers a way to look younger and therefore, feel better. Dr. Gartner is careful however to point out that at the present time most board-certified plastic surgeons do not perform these procedures under local anesthesia. As a result, some patients who want cosmetic surgery but can Februar y 2011
7
procedures in a safe and sterile setting such as the one at the Gartner Plastic Surgery & Laser Center. “I have a sterile, Medicare-certified operating room equipped with everything that would be available in a regular hospital setting,” Dr. Gartner emphasizes.
p Shown here, is how a patient looked before Dr. Gartner performed her facelift and after. Again, for suitable patients Dr. Gartner can perform this procedure while the patient is awake, with local anesthesia and oral sedation.
or will not undergo general anesthesia, will seek the services of physicians who are not board certified plastic surgeons or who are possibly specialists in other related fields. Some of these physicians are willing to perform certain cosmetic procedures with the patient remaining awake and being administered local anesthesia. Additionally concerning to Dr. Gartner is the fact that when only a local anesthetic is used, some procedures can legally
be performed within a physician’s office. For patients who cannot tolerate general anesthesia, for whatever reason, Dr. Gartner wants to emphasize the importance of finding a board-certified plastic surgeon such as himself, who is highly skilled in the specialized techniques necessary for a successful cosmetic surgery outcome. Furthermore, he knows that it is crucial that patients undergo these
Electing to have plastic surgery is an important decision. Whether for a minor imperfection or a significant problem that drastically affect’s one’s appearance a potential patient should get all of the facts before proceeding. Dr. Gartner spares no effort to ensure that every patient who consults with him leaves his office with a complete understanding of what his or her procedure will entail. Then patients who choose to go ahead can be assured that Dr. Gartner is impressively trained and highly skilled in the most advanced cosmetic surgical techniques that will produce the beautiful results each individual patient desires. With every appearance-enhancing procedure he performs, Dr. Gartner has the distinct pleasure and satisfaction of knowing that he has transformed someone’s life for the better. Gartner Plastic Surgery & Laser Center is located at 3 Winslow Place, Paramus NJ. For more information or to make an appointment, please call (201) 546-1890. For an appointment at Dr. Gartner’s Eatontown office, located at 44 Monmouth Road, Eatontown NJ, please call (732) 389-0909.
p The state of the art operating room at the Gartner Plastic Surgery & Laser Center is Medicare certified and equipped with everything that would be available in a regular hospital setting.
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New Jersey Physician
Marketing
The Importance of
Marketing Your Specialty Practice In Today’s Competetive Healthcare Environment Submitted by Christopher G. Monaco, Executive Director – Marquis Medical Practice Marketing, LLC
Today’s healthcare marketplace is more competitive than it was just last year. Every year there are more and more practices popping up in and around your community. You may or may not be aware, but your competitors are probably doing some type of marketing. They
Top 5 Reasons to market your practice: 1. You’ve been in practice for years, but most physicians in your area do not refer to you. 2. Y ou are new to the area and referring physicians don’t know anything about you or your practice.
family docs out to dinner, internet advertising
3. Y ou want to secure and protect your current referral base from new or existing competition in your area.
or maybe they even have their office manager
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Februar y 2011
9
Statehouse
New Jersey Statehouse Weinberg-Vitale Bill to Strengthen NJ Public Health Council Approved in Senate Measure Would Ensure Broader Representation, Direct Council to Identify Health Funding Available to the State TRENTON – A bill sponsored by Senate Health, Human Services and Senior Citizens Committee Chairwoman Loretta Weinberg and Committee Vice Chair Joseph F. Vitale which would strengthen the role and membership of the New Jersey Public Health Council was approved today by the Senate by a vote of 29-10. “Considering that New Jersey’s public health dollars are stretched to the absolute limit, we need a public agency with broad representation of all facets of the health care industry to seek out funding wherever it may exist,” said Senator Weinberg, D-Bergen. “Under this bill, the Public Health Council will not only serve to advise State policy and regulation-makers about the science of health care, but will also be called upon to identify untapped federal and private funding sources for which the State can apply. It would make the Public Health Council relevant to the needs and demands of a 21st Century public health care system.” “Since it was scaled back in 2005, the Public Health Council has acted on the periphery of New Jersey’s public health programs, providing limited advice on the direction of health policy in the State,” said Senator Vitale, D-Middlesex. “Through this bill, we wanted to empower the agency to once again make important policy and funding recommendations to make sure that we take the politics out of health care and apply for all the funds for which New Jersey qualifies. At a time when the health care picture nationally is in a state of flux, we absolutely need the Public Health Council to make sure New Jersey’s health programs are meeting the shifting health care needs of our people.” The bill, S-2659, would revise the Public Health Council’s membership, and restore the functions, powers and duties of the Council. Under the bill, the Council’s membership would be amended in order to better reflect a broader representation of public health interests. Specifically, the revised Council would include: • a dentist licensed to practice in New Jersey, appointed by the Governor; • a person who is knowledgeable by way of education or professional experience in health-related aspects of terrorism, appointed by the Governor;
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New Jersey Physician
• a dean of a school of public health, or a regionally accredited institution of higher education in New Jersey, appointed by the Governor; • a health insurance carrier licensed to do business in New Jersey; appointed by the Governor; • a physician who specializes in infections disease, appointed by the Senate President; • a State-licensed public health officer, appointed by the Senate President; • someone who represents a philanthropic foundation that funds research on public health issues, appointed by the Senate President; • a licensed pediatrician, appointed by the Assembly Speaker; • a person with a demonstrated expertise in maternal and child health, appointed by the Assembly Speaker; and • a licensed health care professional with a demonstrated knowledge and interest in public health, appointed by the Assembly Speaker. Under the bill, each member would serve for a term of four years, as opposed to the seven-year terms prescribed for under current law. The members of the Public Health Council serving on the effective date of the bill would continue to serve until the expiration of their respective terms. “Under the terms of the current law, many of these specialized areas of health care have little to no representation on the Public Health Council,” said Senator Vitale. “We want an organization which can provide comprehensive advice and represent a broad set of interests. Through this bill, we can transform the Public Health Council into an advisory agency which represents and reflects the many varied areas of interest within the public health arena – from pediatric to insurance providers, dentists to anti-terror experts.” The bill would also direct the Public Health Council to resume some of the duties it had prior to an executive reorganization which took place in 2005 and essentially relegated it to a diminished advisory role. The revamped Public Health Council would be responsible for identifying public and private grants and other funding sources for public health purposes that may be available to the State, and advise the Commissioner of Health of its findings. It would also report annually to the Governor and the Legislature on its activities and include in its report such recommendations for legislative or administrative action as it deems appropriate. “At a time when more and more people depend on some level of public assistance to access health care, we cannot afford to leave any money on the table, whether its in the form of federal grants or private research dollars,” said Senator Weinberg. “In addition to restoring the Public Health Council to its former responsibilities, we need the Council to be creative
New Jersey Statehou se about finding funding solutions for our many publicly-funded health care programs. At the end of the day, this will allow State health care administrators to do more with less, and help the greatest number of people possible access decent, quality health care.” The bill now heads to the Assembly for consideration.
Four States Get Waivers to Carry Out Health Law
, or fewer than 2% of all those with employer sponsored insurance
Delay In Physician Pay Reduction Posted by Frank Ciesla The 2012 Federal budget proposed by the Obama Administration delays the threatened 28% cut in Medicare payments to doctors for two (2) more years, until after the elections. This approach continues kicking the can down the road, and does not permanently resolve the
situation. At a hearing on Tuesday, February 15, 2011, both Senate Finance Committee Chair Max Baucus, a Democrat, as well as Orrin G. Hatch, the Republican ranking member, challenged Health and Human Services Secretary Kathleen Sebelius to come up with a permanent overhaul of the Medicare physician pay formula. The lack of a permanent solution continues to put at risk doctor compensation for providing services to Medicare beneficiaries. It also does not address the need to reduce Medicare expenditures so as not to continue growing the national deficit. As Senator Alan Simpson co-chair of the Debt Reduction Commission, stated on cable news, it is necessary to reduce physician compensation
By Robert Pear, Sourced from the NY Times The Obama administration said that it had granted broad waivers to four states allowing health insurance companies to continue offering less generous benefits than they would otherwise be required to provide this year under the new federal health care law. The states are Florida, New Jersey, Ohio and Tennessee, the administration told Congress. Lawmakers said that many other states, insurers and employers needed similar exemptions from some of the law’s requirements and would seek waivers if they knew of the option. Steven B. Larsen, a top federal insurance regulator, said the waivers would allow many consumers to keep the coverage they had, a goal often espoused by President Obama. Under the law and rules issued by the administration, health plans this year must generally provide at least $750,000 in coverage for essential benefits like hospital care, doctor’s services and prescription drugs. In states granted the waivers, many health plans with much lower annual limits on coverage may continue to operate. “Unfortunately, limited benefit plans, or minimed plans, are often the only type of insurance offered to some workers,” said Mr. Larsen, who is director of the federal Center for Consumer Information and Insurance Oversight. It was to protect such coverage that the administration granted the waivers, he said. Mr. Larsen said the administration had granted temporary waivers t the four states and to more than 900 health plans covering 2.4 million people
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11
New Jersey Statehou se if we intend to have a handle on the Medicare expenditures going forward. Regrettably, the math is simple. If there are more beneficiaries, as there will be with the baby boomers, and society does not want to or cannot afford to increase the Medicare expenditures, the alternatives are to reduce payment to providers or ration care.
Assembly Committee Passes Insurance Reform Bill and Bill to Improve EMS System By Mark Manigan Esq and Debra Lienhardt, Esq of Brach Eichler On January 20, 2011, the New Jersey Assembly Health and Senior Services Committee unanimously approved a bill (A3247) that would improve the authorization and prompt payment requirements under the Health Claims Authorization, Processing and Payment Act (HCAPPA). The bill would require insurance carriers to classify medically necessary procedures as covered benefits and would prohibit carriers from remitting payments to hospitals at a rate lower than the contracted rate for patients awaiting transfers to a lower level of care. Under the current system, carriers that receive a request for authorization from a health care provider are only required to respond to the request with a determination as to whether the health care service is medically necessary under the member’s insurance plan. This bill requires that carriers that provide authorization determine that the service is medically necessary and that it is a covered benefit under the insured’s plan. The bill also provides that, while a patient remains in the hospital awaiting authorization from the insurance carrier to be transferred to another
facility to receive medically necessary services that are not rendered by the hospital, the carrier must remit payment to the hospital in connection with the contracted acute care rate until the patient is transferred to another health care facility. On the same day, the committee also approved a second bill (A2095) that would improve New Jersey’s Emergency Medical Services (EMS) system. This bill would require all ambulances to become licensed by the New Jersey Department of Health and Senior Services (DOH), and also establishes an Emergency Medical Care Advisory Board to study and improve the EMS program in New Jersey. The bill will require licensure of the following individuals: 1) a paramedic to staff a mobile intensive care unit; 2) an EMT to staff a licensed ambulance; and 3) an emergency medical responder to respond to 9-1-1 calls. Paramedics, EMTs and emergency responders would be required to undergo criminal history background checks as a condition of licensure. DOH would be required to make available to the public a current list of licensed paramedics and EMTs on its website. Pursuant to the bill, DOH must ensure or arrange for the provision of advanced life support pre-hospital care in response to 9-1-1 calls. Paramedics would be able to perform advanced life support services provided they 1) maintain direct voice communication with and are taking orders from a licensed physician or physician directed registered professional nurse, both of whom are affiliated with a mobile intensive care service; or 2) operate under standing orders from a licensed physician that were developed or approved by a mobile intensive care program. We will continue to monitor the progress of these bills. Both will now go to the Assembly floor and await posting for a full vote.
REGISTRATION OPEN! March 31 & April 1, 2011 Register Now for NJMGMA PMC 2011
“TUNE UP YOUR PRACTICE FOR HEALTHCARE REFORM“ Don’t miss this exciting two-day educational session at the Taj Mahal Hotel and Casino in Atlantic City, NJ. Featuring Naomi Judd, Grammy Award winning country singer, and former nurse, discussing how an unexpected life threatening diagnosis at the height of her career changed her outlook and focus on life. With an unwavering optimism and characteristic inner strength, Naomi stepped away from the spotlight to explore paths that have led to new successful endeavors. Outstanding program content, fantastic breakout sessions and a spectacular location…bigger and better than last year’s conference and the one you won’t want to miss! PMC 2011 will offer extensive educational breakouts that will touch on all aspects of your practice in today’s healthcare environment.
New Jersey Medical Group Management Association
12
New Jersey Physician
More Details and Registration Available at www.pmc2011.org
STATLaw
Legal Issues
Provided by Kern, Augustine Conroy & Schoppmann, PC
Strike Force Sweep Charges 111 Persons with Health Care Fraud
Two of the fugitives, including a physician,
beneficiaries with written notice of their right
have been captured since being identified on
to contact a Quality Improvement Organization
the website. The OIG is seeking more than
with concerns about the quality of care they
170 fugitives on health care fraud and abuse
received. More information is available at:
charges.
http://www.cms.gov/qualityimprovementorgs/.
involving more than $225 million in false
HHS Adopts Enrollment Rules Targeted at Fraud
billing tied to criminal false claims, kickbacks,
The title of new HHS rules that become
Employment and Ignorance No Defense
money laundering and aggravated identity
effective March 25, 2011, says it all: Medicare,
theft (see http://www.justice.gov/opa/pr/2011/
Medicaid, and Children’s Health Insurance
February/11-ag-202.html).
Program: Additional Screening Requirements,
The Medicare Fraud Strike Force, on February 17th, charged 111 persons-including doctors, nurses, and health care companies and executives-in nine cities for their alleged participation in Medicare fraud schemes
The
multi-agency
team of federal, state, and local investigators
Application
Fees,
Temporary
Enrollment
uses Medicare data analysis and community
Moratoria,
Payment
policing to find and prosecute fraud. The
Compliance Plans for Providers and Suppliers.
defendants included three physicians and
Among other things, the new rule categorizes
one physical therapist in Brooklyn, and the
providers and suppliers by level of “risk”, with
schemes involved DME, home health, physical
additional screening activities conducted at each
therapy, chiropractic, podiatry, psychotherapy,
level, such as unannounced site visits to those
diagnostic testing, and prescription drugs.
labeled as “moderate” risk. Although intended
Two days earlier, twenty persons in Florida,
to target those who are unqualified to enroll,
including three physicians, were charged with
all providers and suppliers should be aware of
over $200 million in health care fraud involving
the new rules, including provisions allowing
mental health services and sleep studies.
for payment suspension during an investigation
Suspensions
and
of a “credible allegation of fraud.” For more information, see: http://www.federalregister.
OIG Launches Most Wanted List
gov/articles/2011/02/02/2011-1686/medicaremedicaid-and-childrens-health-insuranceprograms-additional-screening-requirements.
Just two weeks prior to the government’s
In an unpublished opinion, the New Jersey Appellate Division has upheld the Board of Chiropractic Examiners in its disciplinary action against a chiropractor who conducted sensory nerve conduction threshold testing. The chiropractor argued that he was not prohibited from performing the tests, only from billing for them and, as a per diem employee of another chiropractor, did not actually bill for the services and, in fact, was unaware that the billing was prohibited. The Court agreed with the Board that a licensee is held to the same professional standards and obligations whether
or
not
employed
by
another
licensee. By certifying for billing purposes that he performed the tests and that they were reasonably necessary, the employee violated the Board’s diagnostic testing rule. Both the Chiropractic Board and the State Board of Medical
Examiners
have
comprehensive
diagnostic testing rules.
massive health care fraud takedown, the U.S. Dept of Health & Human Services’ (HHS) Office of Inspector General (OIG) launched its Most Wanted Fugitives List, at http://oig.hhs. gov/fugitives/, to highlight to the public those individuals sought by authorities on charges of health care fraud and abuse. The list includes a photo and profile of each fugitive, with an online tip form and 24 hour hotline number for reporting information related to a fugitive.
New QIO Notice Requirement Proposed
Find more information on the above items at www.drlaw.com.
The Centers for Medicare & Medicaid Services has proposed a rule that would require most providers and suppliers that participate in Medicare, including clinics and ASCs, to provide Februar y 2011
13
Finance
Medicare Financial Incentives Are Available Do you Qualify?
Provided by Deirdre Hartmann, CPA and Manager Nisivoccia LLP
Keeping up with the constant changes going
provides for a 10% bonus payable to general
on these days in the healthcare field can be
surgeons when they furnish a major surgical
• Certified EHR technology – To receive the
a full time job. Physicians and their practices
procedure in a location defined by Medicare
incentive payments, make sure the EHR
need to be aware of the Medicare and Medicaid
as a Health Professional Shortage Area
technology you’re using or are considering
incentives available to them and take advantage
(HPSA). For a listing of zip codes eligible for
purchasing has been certified by the Office
while the opportunities exist.
physician assistant.
This article
the automatic payment of the HPSA physician
of the National Coordinator for Health
aims to make you aware of programs that are
bonus payment go to http://bhpr.hrsa.gov/
Information Technology. See http://healthit.
available and what actions you need to take so
shortage/. Qualifying general surgeons would
hhs.gov for a listing of products that have
you don’t leave money on the table.
be identified on a claim for a major surgical
been certified. Register as soon as possible.
procedure based upon his or her NPI. If the
You can register before purchasing a system.
Primary Care Incentive Payment
claim is submitted by a physician’s group
• Meaningful User – You have to successfully
Program (PCIP)
practice, the rendering physician’s NPI must
demonstrate
The 2011 Final Physician Fee Schedule which
be included on the line item for the major
consecutive 90-day period in your first
was published in the Federal Register on
surgical procedure in order to determine if
year of participation (and a full year in
November 29, 2010 provides for a 10% bonus
the procedure is eligible for payment under
all subsequent years) to receive the EHR
payable to primary care providers. A primary
the HSIP program. The bonus will be paid
care provider is defined as either a physician
quarterly in 2011 by the Medicare intermediary
• Attestation – You must legally attest through
who is enrolled in Medicare with a primary
automatically if the provider has met the above
Medicare or Medicaid’s website that you have
specialty designation of family practice,
criteria.
met all of the eligibility criteria to qualify for
internal medicine, pediatrics or geriatrics.
“meaningful
use”
for
a
incentive.
the incentive payments. Attestation begins
Non-physician practitioners can also qualify if
Medicare and Medicaid Electronic
in April 2011, with the first EHR incentive
they are enrolled in Medicare with a specialty
Health Record (EHR) Incentive
payments being paid in May 2011.
designation of nurse practitioner, certified
Programs
clinical nurse specialist or physician assistant.
The Medicare and Medicaid EHR Incentive
Although these are only some of the programs
The provider allowable charges for primary
programs will provide incentive payments
available, keeping you informed can help you
care services must represent at least 60% or
to an eligible professional who becomes a
achieve financial benefits. Wishing everyone a
more of their Medicare allowed charges in
meaningful user of EHR technology.
Happy and Prosperous New Year!
the prior year. To be eligible for the PCIP the
incentive payments are based upon individual
primary care physician must submit the claim
practitioners. If you are part of a group practice,
Deirdre M. Hartmann is CPA and Manager
for primary care services indicating his or her
each eligible professional in the group can
of Nisivoccia LLP, a multi-dimensional CPA
National Provider Number (NPI) as rendering
qualify for up to $44,000 from the Medicare
firm with offices in Mt. Arlington and Newton,
physician on the line item for the primary care
program or up to $63,750 from the Medicaid
New Jersey.
service provided.
Program.
accounting and audit services, and maintains
quarterly in 2011 by the Medicare intermediary
• Eligibility - For the Medicare program
practice
automatically if the provider has met the above
an eligible professional is a doctor of
healthcare, technology, municipal government,
criteria.
medicine, osteopathy, dental surgery or
and education, nonprofit and financial services.
dental medicine, podiatry, optometry or
Contact her at Dhartmann@nisivoccia.com.
HPSA Surgical Incentive Payment
chiropractor. For the Medicaid program an
(973) 328-1825.
Program (HSIP)
eligible professional is a physician, nurse
The 2011 Final Physician Fee Schedule also
practitioner, certified mid-wife, dentist or
14
The bonus will be paid
New Jersey Physician
The
The firm offers traditional tax,
specialties
in
sectors
including
New Jersey Women in Healthcare (NJWH) is a new networking group for leading women in healthcare in New Jersey, such as healthcare providers, including physicians and dentists, and key executives in hospitals, nursing homes and other healthcare facilities.
Join us for NJWH’s inaugural event, which will bring together women in healthcare to hear about trends in the healthcare industry and to build their professional networks.
Thursday, March 24, 2011 12:00 to 5:00 p.m. Hilton Woodbridge 120 Wood Avenue South Iselin, New Jersey
Keynote speakers:
Poonam Alaigh, M.D. Commissioner Department of Health and Senior Services
The program kicks off with a networking luncheon at 12 noon. It concludes with a wine tasting and an opportunity to network. In between, you will have the chance to hear the perspectives of two leaders in New Jersey healthcare and meet and mingle with other professional women in healthcare. Admission is complimentary.
Sponsored by
Elizabeth A. Ryan, Esq. President & CEO New Jersey Hospital Association
RSVP to alevine@bracheichler.com 973.364.8389 Health Law Practice Group Women Partners
www.bracheichler.com
Lani M. Dornfeld
Carol Grelecki
973.403.3136
973.403.3140
Debra C. Lienhardt 973.364.5203 Februar y 2011
15
Food for Thought
Tabor Road Tavern Morris Plains, New Jersey By Iris Goldberg
If there are readers who actually follow Food For Thought on a monthly basis, they would have noticed that I did not submit an article for last month’s issue. The reason is one I am sure many can identify with. A painful back ailment that began last July became progressively worse and had kept me away from restaurants and most other places since mid-December. On January 4th I reluctantly underwent a necessary fusion procedure to correct the significant problems that were causing the horrific pain. For the next six weeks I gradually healed from the extensive surgery but the original pain was gone immediately. I will be forever grateful for the excellent care and treatment I received. Although complete recovery takes from three to six months, I am slowly returning to normal life. One of the enjoyable parts of life that I have been able to re-claim is dining out. Last night Michael and I visited the Tabor Road Tavern, right off of Route 10 in Morris Plains. We had never been there but were eager to try it because it is owned by the same group as the Huntley Taverne in Summit, which we always enjoy. As we entered I felt as if I were in a huge ski chalet in the mountains, complete with a high wood-beamed ceiling and wood-burning fireplace. The ambience was warm and welcoming. I thought it was odd, however, for the hostess to ask for our name since there was a table available which we were escorted to without having to wait. We were somewhat disappointed once we were seated because our table was in between two other tables, each only inches away. We clearly heard the conversations at both tables – distracting to say the least. We asked the server if one of the lovely booths was available but he responded that the empty booths were reserved. Determined not to let this slight annoyance ruin our first dinner out in months, we explored the menu. We were intrigued by an appetizer for two consisting of a sampling of Maryland crab cakes, tuna tartare and vegetable spring roll with assorted sauces. This arrived beautifully arranged on a large platter. The spring roll was crisp on the outside with a stuffing of delicately cooked veggies. The crab cakes were not as crisp but the crab filling was delicious. Last but not least, the tuna was fresh and presented interestingly with tortilla chips to scoop with.
16
New Jersey Physician
At this point we couldn’t help but notice the
needs to address certain issues. I do think,
Tabor Road Tavern is located at 510 Tabor
over-attentive service. Two different people
however, that the potential is definitely there.
Road, Morris Plains, NJ. (973) 267-7004
had come over to ask if the appetizer was
The atmosphere is lovely and some of the food
okay. Michael finished his plate first and it was
we sampled was excellent. It’s a bit pricey but
removed. The moment I put my fork down my
with a little effort this could be a great place
plate was whisked away as well. I was starting
for a casual meal that’s a step above a burger
to feel cranky and couldn’t decide if perhaps
and fries. For me, even though the meal was
I had ventured out too soon or if things were
less than perfect, the evening was greatly
really not going as well as they might.
appreciated. I felt so fortunate to be out and
I decided to reserve judgment until after the entrees were served. I had selected char-broiled
about. Sometimes we take even the simplest of pleasures for granted.
hangar steak, rare with Cuban style Yukon Gold potatoes and a salad of watercress. The steak was fabulous. It was seasoned and cooked to perfection. The potatoes were cooked well – crisp on the outside and tender on the inside but I could not eat more than one because of the excessive amount of garlic. In fact, I fed one to Michael so that he might be able to tolerate being close to me. (If you both eat it, the odor isn’t noticeable. This is an undisputed fact). The seasoning on the watercress was off as
The healthcare business environment continues to be increasingly turbulent.
Is your practice
weathering the storm?
well. It was so salty that again, I could not eat more than one bite. Michael thoroughly enjoyed his dish of honey and spice roasted Long Island duck breast served over quinoa with escarole, raisins and pine nuts. I tasted a slice of the duck and had to agree it was perfectly cooked and seasoned. Again, we were asked more than once if everything was alright and again the plates were removed promptly. In fact, although I had
The healthcare experts at Nisivoccia LLP utilize a full breadth of practice management, accounting and tax services to improve efficiency, maximize cash flow and enhance your overall practice. We’ll help you navigate the challenging healthcare climate and set your practice on a course for smooth sailing.
put my fork down, there was still food left on
(973) 328-1825
my plate but it was removed without asking if I
www.nisivoccia.com
was done eating. I wasn’t imagining it. Tabor Road Tavern
Independent Member of BKR International
Februar y 2011
17
Legal Issues
How
Reimbursements
for Over-the-counter Medications
eligible for reimbursement from group health plans (and are “qualified medical expenses” eligible for distribution from HSAs and Archer MSAs). However, the changes in the law amend
Will affect physicians: (NewRules and Requirements)
the definition of what is considered a “medical expense” and restrict the reimbursement of funds used to purchase OTC medicine and drugs going forward after December 31, 2010. Under these new changes, “a distribution from an FSA, HRA, HSA or an Archer MSA
By Michael J. Schoppmann, Esq. Kern Augustine Conroy & Schoppmann, P.C.
for a medicine or drug is a tax-free qualified
As part of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010, patients are now subject to new rules governing reimbursement of the cost of certain over-the-counter (OTC) medications. These rules affect reimbursements under employer-sponsored health plans, health flexible spending arrangements (health FSAs), and
health
reimbursement
arrangements (HRAs),
medical expense only if (1) the medicine or drug requires a prescription, (2) is an over-thecounter medicine or drug and the individual obtains a prescription, or (3) is insulin. As patients seek to utilize these reimbursement vehicles, this will seriously affect the potential liability of physicians who are now frequently asked to provide the documentation required for their patients to be reimbursed. Although, according to the IRS, the patient simply needs to obtain a receipt of payment, the physician must provide documentation which (other than for insulin) is nothing short of an actual prescription , regardless of the fact that OTC medications do not require a prescription for purchase. In responding to recent requests from the medical community for clarification of the need to provide prescriptions for OTC drugs, the IRS has posted a very specific response to this frequently asked question (“FAQ”) on its
as well as health savings accounts (HSAs) and Archer medical savings accounts (Archer MSAs).
18
New Jersey Physician
website: “If your employer’s health FSA or HRA reimburses these expenses, you would provide
Presently, the cost of OTC medicines and
the prescription (or a copy of the prescription or
drugs are deemed “medical expenses” that are
another item showing that a prescription for the
item has been issued) and the customer receipt (or similar third-party documentation showing the date of the sale and the amount of the charge). For example, documentation could consist of a customer receipt issued by a pharmacy that reflects the date of sale and the amount of the charge, along with a copy of the prescription; or it could consist of a customer receipt that identifies the name of the purchaser (or the name of the person for whom the prescription applies), the date and amount of the purchase and an Rx number.”
Princeton Insurance knows New Jersey, with the longest continuous market presence of any company offering medical professional liability coverage in the state.
For purposes of the new rule, a prescription is defined as “a written or electronic order for a medicine or drug that meets the legal requirements of a prescription in the state in which the medical expense is incurred and issued by an individual who is legally authorized to issue a prescription in that state.” However, the new rule does not apply to items that are not medicines or drugs, including equipment (e.g., crutches), supplies (e.g., bandages), and diagnostic devices (e.g., blood sugar test kits). These items will continue to qualify, if they otherwise meet the definition of medical care, which includes expenses for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body.
Leadership: Over 16,000 New Jersey policyholders Longevity: Serving New Jersey continuously since 1976 Expertise: More than 55,000 New Jersey medical malpractice claims handled Strength: Over $1 billion in assets and $335 million in surplus as of September, 2010 Service: Calls handled personally, specialized legal representation, knowledgeable independent agents, in-office visits by our skilled risk consultants Knowledge: New Jersey-specific knowledge and decades of experience Innovation: Three corporate options, gap coverage, specialty reports, practitioner profiles, office practice toolkits
In light of these new requirements, patients will likely seek reimbursement for OTC medications on a more frequent basis. Therefore, physicians should be prepared for a dramatic increase in the number of “prescriptions” they are asked to issue. This is also the area where the risk of potential liability exists. Before simply issuing such documents as “claim documents” or Februar y 2011
19
“reimbursement forms,” physicians and medical
those physicians who contemplate charging
written at that office visit as possible, with as
practices must not issue what will still be legally
for the initial prescription. They may well face
many refills as can be legitimately written. Some
considered a prescription, thereby intended to
regulatory problems at a later date. A physician
practices which have provided advance notice
treat a known medical condition without having
should not write a prescription without first
of such a policy are already charging patients for
first seen and fully examined the
examining and evaluating the patient,
writing prescription refills between visits, in order
patient for that condition. That also
unless this is an established patient
to encourage patients to adhere to a “once a year”
requires properly documenting the
and the physician reasonably believes
protocol.
propriety and medical necessity
a new examination is not required to
of that “prescription.” Further, an
write the new prescription. Further,
additional problem may well arise
if the physician wants to charge
when an established patient requests
the patient to write the initial OTC
that numerous “OTC prescriptions”
prescriptions, this charge would likely
be written, yet is also already taking
be in addition to the fee for the office
prescribed medications which may
visit. However, if the patient complains
interact negatively with the OTC
to a regulatory agency or insurer, such a
medications, and result in patient
combination of fees may well be viewed
injury and a lawsuit. Such a situation clearly
as “excessive.” This could trigger an investigation
requires the prescribing physician be aware
into the documentation about the prescription
of and assess the possible interaction of all the
with subsequent disciplinary action.
medications and drugs, both OTC and non-OTC, which the physician has now “prescribed” for the patient.
Therefore, as a result of this new rule, we anticipate that both new and established patients will want to come to see the physician at least once a year
There may also be additional ramifications for
and have as many of their OTC prescriptions
Looking ahead, every physician and practice must be strongly cautioned not to casually “backdate”, “re-write” or “post-date” prescriptions to ease the burdens imposed upon them by passage of these new rules. Whatever issues may later arise, the falsification of a prescription, whether for OTC or non-OTC medications, will take greater precedence in disciplinary or other regulatory investigations and proceedings and pose a far greater threat to the practice than any other underlying issues. Michael J. Schoppmann, Esq., is a principal in the firm of Kern Augustine Conroy & Schoppmann P.C., which is solely devoted to the representation of healthcare professionals. He may be contacted at 1-800-445-0954 or via email at mschoppmann@ drlaw.com.
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New Jersey Physician
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Shawn Knechtel Widerman & Company Haddonfield, NJ – 800-220-3434
Rory Rineer Professional Liability Agency Harrisburg, PA – 800-375-3056
Robin Voorhees The NIA Group Somerset, NJ – 800-669-6330
John Bisbee Boynton & Boynton Red Bank, NJ – 800-822-0262
Mary Donohue Brown & Brown Metro Mt. Laurel, NJ – 856-552-6330
Carol Maselli Conner Strong Companies Philadelphia, PA – 267-702-1375
Don Roberts USI MidAtlantic Plymouth Meeting, PA – 482-351-4600
Chris Zuccarini Cornerstone Professional Liability Consultants Radnor, PA – 800-508-1355
Kevin Byrne Acorn Professional Services West Conshohocken, PA – 800-454-2429
Tim Hoover The Woodland Group Sparta, NJ – 800-253-1521
Jennifer M. Moser Brown & Brown Bethlehem, PA – 610-974-9490
Patty Schaeffer AON/Affinity Insurance Hatboro, PA – 215-773-4600
William Carey Healthcare Risk Solutions Fort Washington, PA – 800-215-2707
Henry S. Kane Argent Professional Insurance Warren, NJ – 908-769-7400
Richard Petry Glenn Insurance Absecon, NJ – 609-641-3000
Kim Soricelli Arthur J. Gallagher Associates Montclair, NJ – 973-744-8500
Bob Cottone RUE Insurance Trenton, NJ – 800-272-4783
Steven Klinger Professional Consulting Services Livingston, NJ – 973-597-0400
William A. Reilly Joseph A. Britton Agency Mountainside, NJ – 800-462-3401
Burt C. Szerlip BC Szerlip Insurance Agency Little Silver, NJ – 800-684-0876