SBCMS News/Media

CMA/AMA Successful in Getting Congress to STOP Physician Medicare Cuts

U.S. Senate votes to stop nearly all of the Medicare payment cuts facing physicians for 2022

CMA has some good news to share on the federal front:  
Tonight the U.S. Senate voted to stop nearly all of the Medicare payment cuts physicians were facing on January 1, 2022.  Earlier this week, the U.S. House of Representatives passed the legislation which included provisions to increase the debt ceiling – a must-pass bill for Congress and the nation. President Biden is expected to sign the bill before the debt ceiling deadline of December 18, 2021.  Please also see the AMA message below.  

CMA warned Congress that physicians are still on the frontlines fighting the pandemic and their practices have not yet recovered.  Most recently, CMA and CHA joined forces to urge the California Delegation to stop the Medicare cuts.  See the December letter attached.  CMA, the County Medical Societies, and physician leaders across the state met or contacted every Member of the California Delegation about these urgent and devastating cuts that would continue to destabilize physician practices.  In response, nearly 250 Members of Congress sent a letter to House Leadership urging them to stop the payment cuts.  

CMA wants to thank the County Medical Societies, all physician leadership and the physician grassroots that were key to convincing Congress to intervene.  CMA also appreciates the continued leadership of Speaker Pelosi and thanks Minority Leader McCarthy, Senators Feinstein and Padilla, and the California Congressional Delegation for their support.  

Brief Summary:  

1. Medicare Sequestration Cuts Waiver Extended - Extends the COVID-19 waiver of the 2% Medicare sequestration cuts through March 30, 2022; restores 1% of the Medicare sequestration cuts on April 1, 2022 and then on June 1, 2022 all of the Medicare 2% sequestration cuts will resume.  (Note:  2% Medicare sequestration cuts were enacted in 2011 as part of a massive effort to reduce federal spending. All federal programs were cut.)   
2. 3.75% Medicare Fee Schedule Cut Reduced - Congress stopped 3% of the 3.75% Medicare Physician Fee Schedule cuts proposed by the Centers for Medicare and Medicaid Services.  Some physicians will still experience a .75% payment cut.  
3. 4% PAYGO Cut Stopped - Congress fixed the PAYGO provision that would have imposed another 4% Medicare payment cut through 2022.
4. Delayed the Radiation Oncology Alternative Payment Model Demonstration Project until 2023 - CMA will continue to advocate for its permanent elimination.
5. Delayed the Clinical Laboratory Medicare payment cuts - the requirements to report on private rates until 2023.

As the AMA message below from Dr. Harmon suggests, AMA, CMA and all of organized medicine must come together next year to propose proactive legislative reforms to the Medicare payment system to provide annual payment updates to keep pace with rising costs, eliminate unnecessary and harmful budget neutrality cuts, and promote physician-led alternative payment models.  We must convince Congress to overhaul the Medicare payment system soon.

Thanks again to the entire CMA team of physicians and staff for your assistance in stopping these massive Medicare payment cuts – that also impact Medicare Advantage and private sector rates.  It should also be noted that Congress did this in record time this year avoiding yet another Christmas Holiday crisis!     

AMA-AHA Surprise Billing Litigation Filed Today
In other news today, the AMA and the American Hospital Association (AHA) filed a joint lawsuit challenging the Biden Administration’s federal surprise billing regulations that heavily favor the powerful insurance industry and are in conflict with Congressional intent and the balanced law that Congress passed.  Specifically, the challenge is related to the rebuttal presumption given to the median contracted payment rate as the appropriate out-of-network payment rate in the independent dispute resolution process.  AMA and AHA have also asked for a stay of the independent dispute resolution process.  The message and press release are listed below.   See the CMA and AMA comments on the regulations attached.   

Build Back Better Social/Health Care Infrastructure Legislation Awaits Final Determination
Finally, CMA will continue to advocate for the passage of the important health care provisions in President Biden’s Build Back Better social/health care infrastructure plan, including improvements to the Affordable Care Act, allowing Medicare to negotiate drug prices with pharmaceutical companies that will reduce prices by 40-65%, expanding the number of GME residency positions by 4,000, and including the new Pathways to Practice Program that provides scholarships and stipends to minority students who choose medicine as a career.  The bill passed the House in early November and the final negotiations are underway in the Senate. 

MESSAGES FROM THE AMA:

1.    SURPRISE BILLING LITIGATION 
The American Medical Association and American Hospital Association filed a complaint and motion to stay against the federal government today over the misguided implementation of the federal surprise billing law.  What follows is the press release. 

Hospital and physician groups file lawsuit over No Surprises Act final rules that jeopardize patient access to care
December 9, 2021

WASHINGTON —The American Hospital Association (AHA) and American Medical Association (AMA), representing hospitals, health systems, and physicians, sued the federal government today over the misguided implementation of the federal surprise billing law. The associations are joined in the suit by plaintiffs including Renown Health, UMass Memorial Health and two physicians based in North Carolina. 

The lawsuit challenges a narrow but critical provision of a rule issued on Sept. 30, 2021, by the U.S. Department of Health and Human Services (HHS) and other agencies. The provision being challenged ignores requirements specified in the No Surprises Act and would result in reduced access to care for patients. The rule and this flawed provision are set to take effect Jan. 1, 2022. 

The AHA and AMA strongly support protecting patients from unanticipated medical bills and were instrumental in passing the landmark No Surprises Act to protect patients from billing disputes between providers and commercial health insurers. 

The legal challenge became necessary because the federal regulators’ interpretation upends the careful compromise Congress deliberately chose for resolving billing disputes. According to the lawsuit, the new rule places a heavy thumb on the scale of an independent dispute resolution process, unfairly benefiting commercial health insurance companies. The skewed process will ultimately reduce access to care by discouraging meaningful contracting negotiations, reducing provider networks, and encouraging unsustainable compensation for teaching hospitals, physician practices, and other providers that significantly benefit patients and communities.

Congress created an independent dispute resolution process that is required when providers and insurers are unable to reach agreement on payment for out-of-network services from providers who are not under contract with the insurer. However, federal regulators have directed arbiters under independent dispute resolution to presume that the median in-network rate is the appropriate out-of-network rate and limiting when and how other factors come into play. The suit argues that the regulations are a clear deviation from the law as written and all but ensure that hospitals, physicians, and other providers will routinely be undercompensated by commercial insurers and patients will have fewer choices for access to in-network services. 

Importantly, today’s challenge does not prevent the law’s core patient protections from moving forward and will not increase out-of-pocket costs to patients. It seeks only to force the Administration to bring the regulations in line with the law before the dispute negotiations begin.

“No patient should fear receiving a surprise medical bill,” said Rick Pollack, AHA president and CEO. “That is why hospitals and health systems supported the No Surprises Act to protect patients and keep them out of the middle of disputes between providers and insurers. Congress carefully crafted the law with a balanced, patient-friendly approach and it should be implemented as intended.” 

“Congress established important patient protections against unanticipated medical bills in the No Surprises Act, and physicians were a critical part of the legislative solution,” said AMA President Gerald E. Harmon, M.D. “But if regulators don’t follow the letter of the law, patient access to care could be jeopardized as ongoing health plan manipulation creates an unsustainable situation for physicians. Our legal challenge urges regulators to ensure there is a fair and meaningful process to resolve disputes between health care providers and insurance companies.” 

Last month, a bipartisan group of 152 lawmakers urged the Administration to fix the independent dispute resolution provisions, noting the rule’s approach “is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care – the exact opposite of the goal of the law.” 

The AHA, AMA and their co-plaintiffs filed their lawsuit against the departments of HHS, Labor, and Treasury, along with the Office of Personnel Management in the U.S. District Court for the District of Columbia. 

For additional information, please see copies of the filed complaint and motion to stay.

2.    Senate Passes Legislation to Halt Medicare Physician Payment Cuts
This evening, the Senate passed legislation halt Medicare physician payment cuts that were scheduled to take effect on January 1. President Biden is expected to sign the bill into law.

Highlights of the physician payment provisions include:

•    A delay in resuming the 2% Medicare sequester for three months (January 1- March 31, 2022), followed by a reduction to 1% for three months (April 1-June 30, 2022).
•    A one-year increase in the Medicare Physician Fee Schedule of 3% (0.75% less than the conversion factor boost provided for 2021).
•    A one-year delay in the cuts to the clinical lab fee schedule.
•    A one year delay in the Medicare radiation oncology demonstration.

Additionally, the bill will erase the 4% Medicare PAY-GO cut and prevent any additional PAY-GO cuts through 2022.

The AMA released the following statement on tonight’s Senate vote to avert looming Medicare cuts to providers. 

AMA: Patients and Physicians Grateful for Congress Fending Off Medicare Cuts 
December 9, 2021 

Statement attributable to:
Gerald E. Harmon, M.D.
President, American Medical Association    

“The wheels of Congress don’t always move quickly, but today they did move toward preserving the viability of physician practices and maintaining access to care. 
 
“Potential reductions in Medicare payments for physician services hung over the heads of patients and practices like a sword of Damocles. The Senate action today, following a similar House vote this week, would delay the reductions and give Congress time to work on reforms to address the flaws in the Medicare payment system. 
 
“There is no need to wait for the last minute to start working on the systemic problems. These automatic cuts should remind members of the needed reforms. Congress can get a head start on doing the right thing when it reconvenes early next year.” 

Telehealth Expansion Due to COVID-19

President Donald Trump today announced the federal government is immediately suspending HIPAA enforcement and penalties to facilitate use of telehealth for health care services in both the Medicare and Medicaid programs.

As of this morning, March 17, the Centers for Medicare and Medicaid (CMS) has announced that Medicare will immediately expand telehealth coverage for seniors so that they can be treated from home and not risk their own health and that of providers by being required to visit a medical office. 

Please see important information, guidelines and links here:

• CMA Newsroom Article
• CMS Telehealth Fact Sheet
• AP Article

The federal government is working with insurance companies to ensure that necessary adjustments are being made. 

States are being encouraged to expand the use of telehealth in their Medicaid programs for low-income patients. Separately, Medicare Advantage plans offered by private insurers have been allowed to offer telemedicine as a supplemental benefit. 

Physicians should work directly with their telemedicine program vendor or web-based provider for clarification and confirmation of capturing codes and CPTs needed for treatment. Also please see CMS FACT SHEET here. 

As updates continue to be released throughout the day and week, SBCMS and CMA will bring you updates. Please do not hesitate to contact Alison at (909) 273-6000. 
 

CMS completes issuance of new Medicare ID cards

The Centers for Medicare and Medicaid Services (CMS) has now completed the process of mailing new Medicare cards to beneficiaries across all states and territories. The new Medicare ID cards, required under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), contain a unique, randomly assigned Medicare Beneficiary Identification (MBI) number, which replaces the previous Social Security-based number.

CMS also reports that for the week ending January 11, 2019, fee-for-service health care providers submitted 58 percent of claims with the new MBIs. 

CMS is allowing a 21-month transition period (which began in April 2018), during which health care providers will be able to use either the patient’s current Medicare number or the patient’s new Medicare number for all Medicare transactions. The transition period will end December 31, 2019. While providers can continue submitting claims with the old ID numbers during the transition period, physicians are encouraged to use the new MBIs as soon as possible for all Medicare transactions. 

CMS has developed a webpage to help physicians navigate the MBI transition, including slides from the most recent CMS Open Door Forum on the issue. Physicians are also now able to look up their Medicare patients’ new Medicare numbers through Noridian, the Medicare Administrative Contractor’s, secure web portal. Physicians should also talk to their practice managers and health IT vendors now to ensure their systems are ready to accept the MBI.

If your Medicare patients say they did not get a card, instruct them to:

• Sign into MyMedicare.gov to get their new numbers or print official cards. They need to create an account if they do not already have one.
• Call 1-800-MEDICARE (1-800-633-4227) to get their new cards.  
• Continue to use their current cards to get health care services. They can use their old cards until December 31, 2019.

For more information, please visit cms.gov/newcard.

Medicare publishes 2018-2019 influenza vaccine pricing

The Center for Medicare and Medicaid Services (CMS) recently published an update on Medicare’s influenza vaccine payment allowances and effective dates for the 2018-2019 flu season.

The Medicare Part B payment allowance limits for seasonal influenza and pneumococcal vaccines are calculated at 95 percent of the average wholesale price.

Payment allowances and effective dates for the 2018-2019 flu season:​

A new influenza virus vaccine CPT code (90689: Influenza virus vaccine quadrivalent [IIV4], inactivated, adjuvanted, preservative free, 0.25mL dosage, for intramuscular use) has been approved and will be payable by Medicare beginning with dates of service on or after January 1, 2019. This new code will be included in the 2019 Medicare Physician Fee Schedule Database file update and the annual Healthcare Common Procedure Coding System update. The new influenza virus vaccine code 90689 is not retroactive to August 1, 2018. No claims will be accepted for influenza virus vaccine code 90689 with dates of service between August 1, 2018, and December 31, 2018. The payment allowance for 90689 is not yet available, but will be provided when the product pricing information becomes available to CMS.

More information on 2018-2019 influenza vaccine pricing is available in MM10914 or on CMS website.

Last day to change your Medicare participation status for 2019 is December 31

Once again, it’s time for physicians to decide if they want to make changes to their Medicare participation status. Physicians have until December 31, 2018, to make changes for the 2019 participation year.

As always, physicians have three choices regarding Medicare: Be a participating provider; be a non-participating provider; or opt out of Medicare entirely. Details on each of the three participations options are as follows:

• A participating physician must accept Medicare-allowed charges as payment in full for all Medicare patients.
   
• A non-participating provider can make assignment decisions on a case-by-case basis and bill patients for more than the Medicare allowance for unassigned claims. Non-participating physician fees are 95 percent of participating physician fees. If you choose not to accept assignment, you can charge the patient 9.25 percent more than the amounts allowed in the participating physician fee schedule (which equates to 15 percent of the non-participating fees).
   
• Physicians who opt out of Medicare are bound only by their private contracts with their patients. Medicare's limiting charges do not apply to these contracts, but Medicare does specify that these contracts contain certain terms. When a physician enters into a private contract with a Medicare beneficiary, both the physician and patient agree not to bill Medicare for services provided under the contract. As a result of the Medicare Access and CHIP Reauthorization Action of 2015 (MACRA), validated opt-out affidavits signed on or after June 16, 2015, will automatically renew two years after the effective date.

Physicians who want to change their participation status for 2019 must send a letter to Noridian, California’s Medicare contractor, postmarked by December 31, 2018.

The California Medical Association (CMA) also has information on physicians' Medicare participation options in CMA’s health law library document #7209, "Medicare Participation (and Nonparticipation) Options." Health law library documents are free to members at www.cmadocs.org/health-law-library. Nonmembers can purchase documents for $2 per page.

Physicians can also visit CMA’s MACRA resource center at www.cmadocs.org/macra to better understand the payment reforms, how they may impact physician practices and access resources to help with the transition. The center is a one-stop-shop with tools, checklists and information from CMA, the Centers for Medicare and Medicaid Services, the American Medical Association and national specialty society clinical data registries.

Contact: Cheryl Bradley, (213) 226-0338 or cbradley@cmadocs.org.

CMA proposes site-neutral payments for some physician services

The Centers for Medicare and Medicaid Services (CMS) has proposed eliminating the Medicare site of service payment differential for physician services. Under the proposed policy, Medicare would pay the same amount for office visit services provided by physicians in “off-campus” hospital outpatient departments as it would for the same office visit service provided in a physician’s office.

Currently, Medicare pays a “facility fee” that results in a much higher rate for the same service when performed in outpatient clinics owned by hospitals, rather than in a physician’s office. For example, cardiac imaging payments are more than triple when patients receive care at a hospital outpatient department instead of a physician’s office – roughly $2,100 vs. $655.

This rule change would result in significant savings for Medicare and its beneficiaries and foster greater competition in the health care market.

Health care policy experts have demonstrated that this site of service payment differential has incentivized hospitals to acquire physician practices, with an 86 percent increase between 2012 -2015 in number of physician practices owned by hospitals nationwide. This unprecedented trend in hospital acquisition of physician practices has caused provider consolidation in the marketplace that has decreased competition, led to increased prices and premiums in the private sector, and increased Medicare costs. Medicare hospital spending has increased 60 percent since 2000.

UC Berkeley researchers recently reported that 40 percent of California physicians now work for foundations owned by hospitals, up from 25 percent in 2010. Nationwide, nearly 33 percent of physicians were employed by hospitals in 2014 (the most recent data available), up from 29 percent in 2012. 

Most health care economists, policymakers and clinicians are now supporting site neutral payments in Medicare to reverse the policies that have artificially driven hospital-physician consolidation and increased costs. 

The California Medical Association (CMA) believes that two factors led to this hospital-physician consolidation: The higher facility fees for hospital outpatient services and the low Medicare physician payment rates.

Medicare physician payments have remained flat since 2001, and now lag at least 25 percent behind the costs to operate a medical practice. While payments have remained flat, the administrative and reporting burdens of running a practice have dramatically increased. Without the resources to invest in practice infrastructure, such as EHRs and quality improvement activities now required for participation in value-based payment programs, independent practices have been driven to seek resources and assistance from hospitals.   

To reverse the trend in hospitals acquiring physician practices and the consolidation in the market that has increased costs, CMA is recommending the following:

• CMS should eliminate the site of service payment differential for ALL services (not just office visits) and ALL settings (off campus and on-campus outpatient departments, except emergency departments).
• CMS should reinvest the savings achieved by site neutrality in a budget neutral way by reinvesting in physician payment so that independent practices have the resources to remain viable, protect access to care and participate in value-based payment programs.
• CMS should provide a six-month transition period for providers to make adjustments, transition their practices, and maintain continuity of care for their patients.

CMA pushes back on CMS' proposed Medicare payment changes

The California Medical Association (CMA) recently submitted comprehensive comments to the Centers for Medicare and Medicaid Services (CMS) on the proposed 2019 Medicare Physician Fee Schedule and MACRA Quality Payment Program rule.

CMA is supporting CMS’s proposal to substantially reduce the Evaluation and Management (E/M) documentation requirements because it would reduce note bloat, improve workflow, and allow physicians to devote more time to their patients.

However, CMA is strongly opposed to the proposal to restructure payment and coding for (E/M) office visits by collapsing the codes from five to two for both new and established patients. Even with the new proposed add-on codes for prolonged visits, primary care and certain specialties treating sicker patients, the proposal would result in significant payment cuts that would harm physicians in specialties that treat the sickest patients, as well as those who provide comprehensive primary care. Collapsing E/M codes as proposed would jeopardize access to care for the chronically ill and patients with complex conditions.

CMA believes there are a number of unanswered questions and potential unintended consequences that would result from the coding policies in the proposed rule. CMA strongly recommends that CMS work with CMA and the proposed American Medical Association task force to develop alternative solutions.  

CMA also strongly opposes the new multiple service payment reduction policy in the proposed rule, as the issue of multiple services on the same day of service was factored into prior valuations of the affected codes and is an important payment for physicians, as well as patient convenience.

Provisions CMA supports:

• Year 3 of the CMA-sponsored California geographic payment updates and the transition to metropolitan statistical areas
• New payments for technology-based and telehealth services
• E/M documentation reduction
• Eliminating extra documentation requirements for home visits
• Eliminating the prohibition on billing for same-day visits by physicians in the same group or medical specialty

Provisions CMA opposes:

• New E/M payment structure
• Multiple procedure payment reduction
• Reimbursement reduction for new drugs administered in physician offices
• Reporting expansion for physician office labs

For more information:

• CMA’s Comments on the Proposed Medicare Physician Payment Rule
• AMA Summary of the Proposed Rule
• California Geographic Payment Impact Analysis
• Specialty Specific Impacts Including Payment Accuracy Adjustments
• Estimated Impact of CY2019 Evaluation and Management Proposed Policy by Medicare Specialty
• Estimated Impact on Total Allowed Charges by Specialty

Noridian announces improvements to Medicare portal

Noridian, the Medicare Administrative Contractor for California, recently announced improvements to the Noridian Medicare Portal (NMP) that will make it easier for providers to identify reasons behind eligibility-related claim denials. When a claim is denied for eligibility-related reasons, providers can select the link under Claim Status in the “Related Inquiries” portion of the page to access details to assist with determining their next steps.

Effective July 27, 2018, all NMP users can also send secure online messages to Noridian regarding medical reviews or to voice concerns to be addressed by the Noridian CERT liaison teams. With the ability to message Noridian, providers better understand claim review decisions and are better prepared to avoid future denials. Messages sent regarding non-medical review/CERT will be directed to the Provider/Supplier Contact Centers. Additional instructions can be found in the Noridian User Manual and self-paced tutorials.

Noridian also announced that provider enrollment functionality will soon be added to the NMP, allowing physicians the ability to review notification letters, application status and submit correspondence as needed, which will be automatically attached to the application. Having previously enrolled in Medicare is a prerequisite for NMP. This feature will assist providers with ongoing file maintenance.

Additional NMP enhancements include an updated inquiry function providing details for active, inactive, deductible and coinsurance period eligibility for Medicare Diabetes Prevention Program patients.

CMS identifies and corrects errors in MIPS scoring logic

Centers for Medicare and Medicaid Services (CMS) recently released 2017 Merit-based Incentive Payment System (MIPS) performance scores and payment adjustment information for the 2019 payment year. Physicians have been able to request targeted reviews if they believe an error was made in the calculation of their performance score.

The requests CMS received through targeted reviews led them to take a closer look at a few prevailing concerns. Those concerns included the application of the 2017 Advancing Care Information and Extreme and Uncontrollable Circumstances hardship exceptions, the awarding of Improvement Activity credit for successful participation in the Improvement Activities Burden Reduction Study, and the addition of the All-Cause Readmission measure to the MIPS final score. Based on these requests, CMS reviewed the concerns, identified a few errors in the scoring logic and implemented system-wide solutions.

The 2019 MIPS payment adjustments have been corrected for clinicians impacted by the identified issues. Additionally, in order to ensure the budget neutrality that is required by law under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), some clinicians not directly impacted by the corrections will see slight changes in their payment adjustment as a result of the reapplication of budget neutrality. 

These revisions were made to the performance feedback on the Quality Payment Program (QPP) website on September 13, 2018.

Physicians are encouraged to sign-in to the QPP website as soon as possible to review their performance feedback. If you believe an error still exists with your 2019 MIPS payment adjustment, you can request a targeted review until October 15, 2018, at 5 p.m. Pacific Time. This deadline has been pushed back two weeks to allow additional time for providers to access and review their performance feedback.

Physicians, physician groups and accountable care organizations (and their authorized representatives) can access their performance feedback by logging into qpp.cms.gov with the same EIDM credentials used to submit and view their data during the submission period.

Physicians who need assistance can contact the QPP Service Center at (866) 288-8292 or QPP@cms.hhs.gov.

CMS has posted the 2017 Performance Feedback User Guide on CMS.gov to help eligible clinicians and groups understand their 2017 MIPS performance feedback.

CalHIPSO Webinar: MIPS Reporting for 2018

• Maintaining the course: What happens if you don’t change anything from 2017?
• Reviewing the MIPS categories: Which ones will deliver the highest value to your practice and have a positive impact on your MIPS performance?
• Changing the objectives and measures you focus on: How do you know which ones will deliver the highest value and whether you meet the minimum requirements? 
• Doing ok with MIPS today? Keep an eye on 2019. Are you establishing the foundation necessary to hit the ground running in 2019 when MIPS gets real?

Register today!

The California Medical Association was a founding member of CalHIPSO, which was established in 2009 as a federally designated Regional Extension Center to provide education, outreach and technical assistance to help physicians select and implement electronic health records.