Saturday, March 28, 2015



Read the latest medical news for the San Bernardino County area.

CMA applauds U.S. House of Representatives for passing monumental Medicare-CHIP reform in landslide vote, urges U.S. Senate to act swiftly

Sacramento – Today, the California Medical Association (CMA) congratulates the U.S. House of Representatives for passing monumental Medicare reform and the Children’s Health Insurance Program (CHIP) extension, and urgently asks their colleagues in the Senate to do the same before spring recess. The 392-37 vote clearly shows that now is the time to make Medicare reform a reality.

The legislation, H.R. 2, known as the “The Medicare and CHIP Reauthorization Act,” will reform the broken Medicare sustainable growth rate (SGR) physician payment system and extend the expiring Children’s Health Insurance Program. Both of these important reforms will help to improve access to doctors in California for five million seniors on Medicare, one million military families on TriCare and the nearly one million uninsured children currently covered by CHIP.

“It is imperative that the House AND the Senate act before the 21 percent SGR Medicare payment cut takes effect on March 31,” said Luther Cobb, M.D., CMA president. “A drastic cut to physician payments will result in decreased access to care for some of our country’s most vulnerable patients. It’s crucial to the success of our health care delivery system that the bill passes before Congress goes home.”

The SGR legislation is nearly identical to the bipartisan, bicameral Medicare physician payment reform package that three Congressional committees unanimously approved in the last Congress and more than 750 state and national physician organizations, including CMA, supported.

There are more than 1,000 new Medicare enrollees every day in California, yet many physicians are no longer accepting new Medicare patients.

“California desperately needs payment reform to improve access to physicians because Medicare influences all public and private health insurance,” added Dr. Cobb. “Patients are experiencing access to care problems all across the state and H.R. 2 will help alleviate some of that.”

With the new bipartisan agreement between House Speaker John Boehner (R-OH) and Minority Leader Nancy Pelosi (D-CA) on how to fund the SGR fix, CMA is calling on Congress to immediately pass this monumental, fiscally responsible legislative achievement that will lead to meaningful improvements in our health care system.

Medicare RAC court case keeps collections on uncertain footing

The U.S. Court of Appeals for the Federal Circuit issued a decision in early March in a case filed by one of the Medicare Recovery Audit Contractors (RAC) after the Centers for Medicare and Medicaid Services (CMS) changed the timing for the payment of contingency fees on collections. The decision means the auditing program will be put on hold until CMS determines how to contract with its RACs.

The RAC program is responsible for identifying fraud and waste in the Medicare system by detecting improper Medicare payments. Since 2008, when the program started, RACs have been paid immediately after Medicare overpayments are collected from providers – generally within 41 days.

In 2014, CMS proposed a different payment method: paying on collections only after a provider's challenge passed the second of a five-level appeal process. RACs balked at this because providers often appeal the overpayment decisions, causing contingency fees to be delayed anywhere from four months to more than a year.

CMS also required the RACs to create a reserve fund, to be used to repay CMS any contingency fees related to denials overturned on appeal. The original RAC contracts did not include a provision to handle such scenarios after RAC contacts expired.

RAC contractor CGI filed a lawsuit in federal court protesting against the new payment terms, arguing that CMS violated federal procurement law by delaying payments to the RACs beyond fair and usual practices. The CGI lawsuit asked the court to compel CMS to procure new contracts through a time-consuming request-for-proposal process instead of more straightforward commercial bidding.

The federal appeals court agreed with CGI's protest, and now CMS must decide how it wants to contract with RACs. The agency can either rebid the contracts through the general commercial process with the original contingency fee structure from 2008, or it can rebid the contracts through the longer noncommercial process with the new payment terms. This will cause a significant delay for the new contracts and it is likely that they won’t be finalized until early 2016.

Physicians and hospitals got a reprieve last year from the RAC auditing program, while CMS reevaluated its contracts and implements improvements for physicians. Audits were to begin again in the fall of 2015.

The Medicare program has already felt the effects of the scaled-back RAC program, only recouping $48.3 million of overpayments from providers – approximately $768 million less than what RACs collected in the same period the year before.

Is your Medicare practice information up-to-date?

The February issue of CMA Practice Resources (CPR) contained an article discussing the importance of maintaining up-to-date practice demographic information with contracted managed care payors (see “Ensure your practice information is up-to-date with contracted payors”). This advice applies equally to government payors, such as Medicare, that you are enrolled in.

Medicare administrative contractors (MAC), such as Noridian in California, obtain practice contact information from a practice’s Medicare enrollment application, from either the Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or through a paper application. The MAC may contact you by mail, telephone or email, when necessary.

Outdated information may cause delays in payment, and even deactivation of your enrollment status if required actions, such as revalidation, are not completed timely. For example, some physicians recently received notices from Noridian that their National Provider Identifier (NPI) was being deactivated due to lack of response to a revalidation request. While Medicare did send a paper notice to affected physicians, in many cases, the practice had not updated its contact information with Medicare, and the paper notice went to the wrong address.

Most government payors require completion of enrollment forms for updates and changes. To ensure your practice’s information is up-to-date with Medicare, practices are encouraged to do the following:

  • Complete the appropriate enrollment forms through the Internet or on paper to report changes. Changes generally cannot be made by letter.

  • Complete any necessary forms to notify the contractor of changes in your office’s primary point of contact. Many agencies will speak only to the person enrolled, or the primary point of contact on the enrollment form. If you are not the contact, they may not assist you when needed.

  • Notify the MAC or other government contractor of changes in address through the enrollment update process, even if it is to a different suite in the same building.

  • Complete an enrollment update if your correspondence address changes, even if your physical address remains the same.

  • Update all email addresses if they change. Government payors are often using email to contact physicians for needed information. Don’t forget to check your spam or junk folders for any emails that may come from contractors you submit claims to.

  • Update phone numbers and area codes if they change. Don’t expect contractors to search for changes.
The Medicare link to paper enrollment forms and the Internet-based PECOS can be found on the Centers for Medicare and Medicaid Services (CMS) Medicare Provider-Supplier Enrollment page on the CMS website (see left sidebar). Click here for additional information on using the Internet-based PECOS.

Updates may take as little as 30 days, or as long as 120 days. Once the change is completed in the system, the physician will receive written confirmation. Prompt notification to government payors of any change will help ensure there are no disruptions in enrollment or payment for your practice

CMA leaders converge on Capitol Hill to advocate for Medicare fix

This week, 25 California Medical Association (CMA) physician leaders were in Washington, D.C., as part of the American Medical Association’s Legislative Week to urge Congress to enact the bipartisan, bicameral legislation that would repeal the Medicare sustainable growth rate (SGR) and institute a new payment system. The group also asked Congress to reauthorize the State Children’s Health Insurance Program, formerly known as Healthy Families, which is set to expire September 2015.

Medicare SGR

Last year, both houses of Congress were very close to a permanent repeal of the badly broken SGR formula. For the first time in a decade, House and Senate Committees had adopted a bipartisan, bicameral payment system to replace the SGR. Unfortunately, they were unable to agree on how to pay for it, ultimately passing a patch to stop the SGR-triggered payment cuts for the 17th time in 10 years.

Congressional leaders have agreed to carry the bipartisan bill forward in the new Congress and leave it intact. However, there remains strong disagreement on how to pay for the bill, despite the House and Senate leadership’s stated commitment to enact the bill this year. Fortunately, there is a growing chorus of conservative thinkers, such as the Wall Street Journal, Americans for Tax Reform and the Galen Institute, who have all told Congress that the projected SGR cuts are “phony” – lawmakers having never implemented the SGR over the last decade, instead adopting short-term patches year after year to stop the cuts – and therefore, the repeal itself does not need to be offset with corresponding funding. If Congress accepts this policy, they will only need to find an additional $30 billion to pass the bill.

Luther Cobb, M.D., CMA president, told Congress that half of California physicians are over the age of 55 and nearing retirement. Passage of Medicare payment reforms would bring the stability and resources necessary to physicians to keep them in practice. He also said that requiring financial offsets for the SGR is akin to a “pay-day loan” and a waste of federal resources. The cumulative cost of the patches now total more than the entire repeal legislation will cost. On behalf of CMA, Dr. Cobb urged Congress to move quickly to protect California’s seniors and military families.

Meaningful use reform and ICD-10

CMA physician leaders also met with Congress, the president’s Medicare staff at the White House and the new head of the Centers for Medicare and Medicaid Services (CMS), Andy Slavitt, about ICD-10 implementation and the burdensome meaningful use electronic health record program. CMA asked CMS to thoroughly test ICD-10 before implementation and suggested that if the testing shows problems, the program should be delayed. CMA physicians also vigorously urged immediate and sweeping reform to the meaningful use program, with Dr. Cobb telling key decision-makers that while the program was intended to facilitate the exchange of patient information to improve care,  it has only hindered participation in the program, imposed unnecessary administrative burdens, disrupted workflow, interfered with patient care and created substantial frustration among physicians. CMA urged decision-makers to require interoperability; align the quality and meaningful use reporting programs; eliminate the all-or-nothing approach, allowing physicians to get credit for the requirements they have met; eliminate the measures that are beyond a physician’s control, such as the patient portal; provide timely feedback; and get rid of the penalties.

Contact: Elizabeth McNeil,

CMS extends meaningful use EHR attestation deadline to March 20

The Centers for Medicare and Medicaid Services (CMS) has extended the deadline for physicians to attest to meaningful use for the Medicare Electronic Health Record (EHR) Incentive Program 2014 reporting year. While the original deadline was February 28, physicians now have until 11:59 p.m., EST, on March 20, 2015, to attest. 

CMS extended the deadline to allow providers extra time to submit their meaningful use data, but urges providers to begin attesting for 2014 as soon as they can.

This extension also allows eligible professionals, who have not already used their one “switch,” to switch programs (from Medicare to Medicaid, or vice versa) for the 2014 payment year. After that time, eligible professionals will no longer be able to switch programs. 

Medicare-eligible professionals must attest to meaningful use every year to receive an incentive and avoid a payment adjustment. Providers who successfully attest for the 2014 program year will:

Note: The Medicare extension does not affect deadlines for the Medicaid EHR Incentive Program. Additionally, the EHR reporting option for the Physician Quality Reporting System (PQRS) has been extended until March 20, 2015. The California Medical Association will publish more information on the PQRS program extension as it becomes available. 

How to Attest
Submit your data to the Registration and Attestation System, which includes 2014 Certified EHR Technology (CEHRT) Flexibility Rule options. 

Tips for speed:

  • Attest during non-peak hours, such as evenings and weekends
  • Start now to:

Check that your information is up-to-date
Begin entering your 2014 data

To learn more, see the Educational Resources on the CMS EHR Incentive Programs website. 

For help, call the EHR Information Center at (888) 734-6433.


CMS to hold Medicare claims for first two weeks of January

Last week the Centers for Medicare and Medicaid Services (CMS) announced it would hold claims for services paid under the 2015 Medicare physician fee schedule due to technical errors discovered after the new fee schedule was published.

Medicare Administrative Contractors (MACs) will hold claims containing 2015 services for the first 14 calendar days of January 2015 (Thursday January 1 through Wednesday January 14) to allow time for CMS to correct the errors.

The hold should have minimal impact on provider cash flow as, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt.

Claims for services rendered on or before Wednesday December 31, 2014, are unaffected by the 2015 claims hold and will be processed and paid under normal procedures and time frames.


CMA creates new resource summarizing Medicare incentive and penalty programs

Over the past few years, Congress has created a number of programs that call for payment incentives and reductions (referred to as “adjustments” by the Centers for Medicare and Medicaid Services) that impact physicians and their practices. At their inception, most of these programs offered an incentive to participate. However, most of the programs are entering their penalty phases, with complex and potentially conflicting requirements and implementation processes.

To help physicians understand how these programs will affect their practices, the California Medical Association (CMA) has created a new resource, “Medicare Incentive and Penalty Programs: What physicians need to know.” The resource is available free to CMA members in the resource library at


Congress passes a number of health care provisions in the current budget

Congress narrowly passed a $1.1 trillion federal budget that will fund most of the federal government through September 2015. Below is a summary of key health care provisions in the bill.

  • Within the bill, Congress expressed concern that there had not been adequate opportunity for public comment on bundling of surgical codes in the final rule of the Medicare Physician Fee Schedule. The budget bill says that the appropriate methodology has not been tested to ensure that patient care and patient access are not negatively impacted and ponderous administrative burdens placed on providers. It asks the Centers for Medicare and Medicaid Services (CMS) to reconsider that fee schedule provision.
  • The budget includes $5.4 billion of emergency funding to prepare for and respond to the Ebola outbreak.
  • The National Institutes of Health will received $30.3 billion (an increase of $150 million), including $283 million for Ebola-related research.
  • CMS receives no increase in funding over last year ($3.6 billion).
  • The Centers for Disease Control and Prevention (CDC) will receive money to combat prescription drug abuse around the country. Twenty million dollars has been set for prevention of drug abuse and another $12 million has been included under the Substance Abuse and Mental Health Services Administration for the states to expand treatment services for drug addiction. This funding is also expected to support activities to establish or expand prescription drug monitoring databases of physicians writing prescriptions for opiates and pharmacists filling prescriptions.
  • The bill looks at the Medicare Recovery Audit Contractors (RAC) and how audits may be reducing patient access to care. The bill directs CMS to provide education to providers on error reduction. It also asks the agency to develop procedures to reduce backlogs of claims and hearings and asks CMS to provide education to RAC contractors to improve the accuracy of their audits.
  • The bill urges the Office of the National Coordinator for Health Information Technology to decertify electronic health records products that block the sharing of information and to certify only those products that meet current meaningful use program standards.

Lame duck session of Congress adjourns, leaving SGR reform until 2015

In the final hours of the lame duck session, Congress passed a $1.01 trillion spending bill that will keep most of the federal government funded through next September, but it failed to pass a fix for the Medicare sustainable growth rate (SGR). Congress will leave it to be addressed before the April 1 deadline next year, when physicians will be faced with a 21 percent payment cut.

Unfortunately, Congress will begin anew with many new members who have not been a part of the bipartisan, bicameral SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015/S. 2000), which offered a fiscally prudent opportunity for lawmakers to repeal the SGR formula and put Medicare on the path toward a stable, 21st-century program that helps physicians maintain their practices and meets the growing health care needs of the nation’s seniors.

Three committees came to an agreement on reform in 2014, but the new year will bring not only new members, but new committee chairs. However, most of the new committee leadership on both sides of the aisle have said they will likely continue to support the SGR bill.

While Congress’s inability to address this issue once again is frustrating, there continues to be momentum on the SGR. Significant progress is being made on the funding – a point of contention that led to the 17th SGR patch earlier in 2014.

Working to build on the momentum of the Medicare payment policy agreement and the new emerging consensus that the SGR repeal does not need to be offset with other funding, the California Medical Association (CMA) will make Medicare payment reform a major priority again in 2015. However, there will be limited time after the new Congress convenes before the current SGR patch expires on April 1. The House of Representatives is only scheduled to be in session for 37 days before the 21 percent SGR cut takes effect.

CMA leadership will be in Washington, D.C., in February. We will also be asking physicians to meet with their Members of Congress while they are in their home districts in January. And CMA will launch a major physician and patient grassroots campaign. The California Members of Congress need to continue to hear from their physician constituents. We have never been so close to repealing and replacing the SGR, but we must keep the issue on Congress’s front burner. Otherwise, immigration reform, conflicts around the world and budget issues will consume all of their time and attention.

In addition to inaction on SGR, Congress also failed in the lame duck session to extend the Affordable Care Act (ACA) Medicaid (Medi-Cal) primary care rate increase that expires at the end of 2014. We will be pushing Congress to extend this crucial rate increase.

Physicians are hopeful that Congress will build on the progress made this year so that organized medicine can focus on addressing other important health policy issues. Critical health care issues facing Congress next year include the expiring Healthy Families program, graduate medical education, telemedicine and improvements to the ACA.

Contact: Elizabeth McNeil, (800) 786-4262 or

Potential Medicare pay cuts coming in 2015; participation selections due Dec. 31

It's that time of year again – time for physicians to decide about their participation in Medicare. Physicians have until Dec. 31, 2014, to make changes to their status for 2015. In addition to the annual threat of steep payment cuts as a result of the sustainable growth rate (SGR) formula, another factor for physicians to consider is that 2015 will be the first year that the Centers for Medicare & Medicaid Services (CMS) will impose penalties under the value-based modifier (VBM) program for large medical groups of 100 or more physicians.

As always, physicians have three choices regarding Medicare: Be a participating provider; be a nonparticipating provider; or opt out of Medicare entirely.

The VBM penalties and bonuses will not, however, apply to unassigned claims. That means a nonparticipating physician would not be subject to a VBM penalty. According to CMS, more than 1,000 groups of 100 or more eligible professionals will see payment penalties from the VBM in 2015. Next year will also be the base reporting year for the 2017 penalties imposed on smaller practices.

Other penalties that will be applied in 2015 based on 2013 performance—including those tied to quality reporting, meaningful use and e-prescribing—will decrease the limiting charge amounts that nonparticipating physicians can bill to patients for unassigned claims.

The three participations options are as follows:

  • A participating physician must accept Medicare allowed charges as payment in full for all Medicare patients.
  • A nonparticipating provider can make assignment decisions on a case-by-case basis and to bill patients for more than the Medicare allowance for unassigned claims. Nonparticipating 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 nonparticipating 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.

Physicians who want to change their participation status for 2015 must send a letter to their Medicare contractor postmarked by December 31, 2014.

The California Medical Association (CMA) also has information on physicians' Medicare participation options in CMA On-Call document #7209, "Medicare Participation (and Nonparticipation) Options." On-Call documents are free to members in CMA's online resource library at Nonmembers can purchase On-Call documents for $2 per page.

Additional information can be found in the American Medical Association (AMA) Medicare Participation Kit. The kit contains a detailed explanation of physician options, a calculator and various sample materials for communicating with patients. The Medicare payment calculator will help you estimate how much your total revenues from Medicare patients would change if you switch your Medicare status from participating to non-participating.

The next SGR Medicare payment cut of ~21 percent is slated to take effect on April 1, 2015, unless Congress passes legislation to stop the cut which they have done 17 times. CMA will be working with AMA to stop the cuts and pass the SGR repeal and Medicare payment reform legislation (HR 4015/S 2000) before April 1.

Contact: Michele Kelly, (213) 226-0338 or




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