Thursday, May 26, 2016



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

CMS releases draft MACRA regulations

The Centers for Medicare and Medicaid Services (CMS) on Wednesday released a 962-page proposed rule that lays out the agency's plan for implementing last year's groundbreaking Medicare reform law, the Medicare Access and CHIP Reauthorization Act (MACRA).

Ahead of CMS’ release of the rule, physician leaders testified before the U.S. House of Energy and Commerce Committee’s Subcommittee on Health during a special MACRA hearing last week. The physicians expressed cautious optimism and said the law represents a critical opportunity to enhance flexibility and innovation in health care that can lead to improved care and better outcomes for patients, but the law also needs to allow physicians to focus on practicing medicine by aligning and simplifying quality reporting programs.

“MACRA makes significant improvements over the current system, including the repeal of the flawed sustainable growth rate formula and giving the Centers for Medicare and Medicaid Services an opportunity to reset and improve performance measurement as well as other requirements,” said Barbara McAneny, M.D., immediate past chair of the American Medical Association (AMA) Board of Trustees, who testified at the hearing. “By increasing the availability of alternative payment models, CMS will spur innovative delivery models focused on enhanced care coordination that can lead to better outcomes for patients.”

The proposed regulations
While there has not yet been time to digest and dissect the entire 962-page regulation, initial reviews indicate that CMS has listened to the input provided by the California Medical Association (CMA), AMA and others in organized medicine over the past year. Since MACRA was passed last spring, organized medicine has been providing extensive physician feedback on MACRA implementation.

Among other issues, the proposed rule addresses questions about elements of MACRA's Merit-Based Incentive Payment System (MIPS), including:

Quality: Clinicians would choose six measures to report, rather than the current requirement of nine, from among a range of options that accommodate differences among specialties and practice settings.

Advancing care information: Clinicians would be able to choose customizable measures that reflect how they use technology in their day-to-day practice. Unlike the existing meaningful use program, this category would not require all-or-nothing electronic health record measurement or redundant quality reporting.

Clinical practice improvement activities: Physicians would be rewarded for clinical practice improvements, such as activities focused on care coordination, patient engagement and patient safety. Clinicians would select activities that match their practices’ goals from a list of more than 90 options.

CMA and AMA will continue to work closely with CMS as the agency revises the regulations over the coming months.

Physicians show cautious optimism for MACRA during Capitol Hill meeting

Physician leaders expressed cautious optimism for the landmark Medicare payment reform law (known as MACRA) during a key congressional committee hearing on April 19. The physicians said the law represents a critical opportunity to enhance flexibility and innovation in health care that can lead to improved care and better outcomes for patients, but the law also needs to allow physicians to focus on practicing medicine by aligning and simplifying quality reporting programs.

“MACRA makes significant improvements over the current system, including the repeal of the flawed sustainable growth rate formula and giving the Centers for Medicare and Medicaid Services (CMS) an opportunity to reset and improve performance measurement as well as other requirements,” said Barbara McAneny, M.D., immediate past chair of the American Medical Association Board of Trustees. “By increasing the availability of alternative payment models, CMS will spur innovative delivery models focused on enhanced care coordination that can lead to better outcomes for patients.”

Dr. McAneny was one of four physicians who spoke at a hearing of the U.S. House Energy and Commerce Committee’s Subcommittee on Health. Together, they highlighted the three necessary steps to ensure MACRA’s successful implementation:

  • Consolidating performance reporting. The new regulations will need to move away from the current pass-fail programs to accommodate the needs of all practices, specialties and patient populations. CMS also will need to streamline the existing burdensome reporting requirements and improve the timing of feedback reports for physicians.

  • Broadening alternative payment models. MACRA regulations must establish a clear pathway for rapid approval and implementation of physician-focused alternative payment models that establish different approaches to delivering patient care. CMS must also avoid adding burdensome requirements that cause resources to be spent on administrative costs rather than helping patients.

  • Improving measurement. The physicians pointed to needed improvements including elimination of the program flaws that make practices with high-risk patients more susceptible to penalties; timely data reports; and suitable methods for attribution and resource use.
"Currently, physicians view measurement as burdensome, inaccurate, and often outdated," said Dr. McAneny. Reporting requirements are extremely costly, she said, with estimates finding that practices spend more than 750 hours per physician annually to report quality measures, with an associated price tag of more than $15.4 billion per year nationwide. Dr. McAneny also said quality measurement reporting and data requirements should be standardized across payor type to avoid duplication.

The other physicians testifying at the hearing agreed on the great potential of MACRA if it is thoughtfully implemented based on physician feedback.

“We believe that the work needed to bring about the change in how physicians provide medical care that will make MACRA successful will mean better care for patients, better professional experience for physicians and their medical teams, and better control of health care costs,” said Robert Wergin, M.D., chair of the American Academy of Family Physicians' Board of Directors.

CMS’ proposed regulations are expected this spring

CSU and palliative care coalition launch eduction programs on advance care planning and billing

In response to the nation’s growing demand for physicians trained in advance care planning conversations, the California State University Institute for Palliative Care has partnered with the Coalition for Compassionate Care of California to co-design a comprehensive continuing education curriculum for health care professionals.

New this year, Medicare providers can be reimbursed for advance care planning conversations with patients. The newly implemented reimbursement provides an impetus for clinicians to spend time exploring patient health care preferences and documenting goals of care.

“Patients want to have these conversations with their providers, and providers need to be paid for the time a meaningful conversation requires,” said Helen McNeal, executive director of the CSU Institute for Palliative Care. “The problem is that clinicians haven’t learned how to talk about advance care planning with patients, and their billing departments don’t know how to use the new billing codes.”

The new online curriculum, "Effective Advance Care Planning: Skills Building for the Entire Organization," provides detailed information about the critical components of advance care planning and billing in an accessible, cost-effective format. Due to their online format, health care professionals from around the country can take the courses at a time and place convenient to them.

Starting this May, the following self-paced courses will be open for registration:

  • Effective Advance Care Planning Fundamentals
  • Facilitating an Advance Care Planning Conversation
  • Building Engagement with Advance Care Planning
  • Billing for Advance Care Planning Conversations
“Reimbursement for advance care planning is a game changer,” said Judy Thomas, CEO of the Coalition for Compassionate Care of California. “Advance care planning is an essential component of patient-centered, quality health care. Professionals with advance care planning expertise are able to identify and clarify individuals’ choices regarding medical treatment.”

For more information, click here.

CMA opposes proposed changes to duals demonstration

The Department of Health Care Services (DHCS) recently released a series of proposals that would change the Coordinated Care Initiative (CCI) enrollment process to 1) passively enroll beneficiaries into Cal MediConnect; and to 2) streamline enrollment by allowing plans to eliminate or dramatically reduce the role of the enrollment broker.

The California Medical Association (CMA), in partnership with Justice in Aging and other patient advocacy groups, signed a joint letter strongly opposing the proposals.

The Coordinated Care Initiative was authorized by the state in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program began with a three-year demonstration project that expected to see a large portion of the state's dual eligible beneficiaries transition to managed care plans.

Experience shows that passive enrollment strategies result in high opt-out rates, confusion, disruption in care, distrust of managed care and high costs to plans.

"These strategies simply do not work," the letter said. "The proposed enrollment changes ignore lessons learned from implementation thus far, and require substantial resources from DHCS, the plans, the enrollment broker and the stakeholder community to implement – resources that should be leveraged on improving the quality of the program and the beneficiary experience and thus promote retention."

Throughout the development of the Coordinated Care Initiative, DHCS and the Centers for Medicare and Medicaid Services (CMS) repeatedly promised to protect beneficiaries through the complicated transition into managed care. Yet, DHCS and CMS moved forward with program implementation, ignoring stakeholder recommendations to slow down and conduct additional systems testing. As a result, beneficiaries experienced significant disruption and confusion, and anticipated enrollment goals were not met.

Today, two years into implementation, health plans are just starting to deliver the coordination of benefits promised under this new delivery model. The enrollment proposals ignore DHCS’s own evaluation data and threaten to revert CCI back to the enrollment chaos of early implementation.

Click here to read the letter.

For more about the duals program, visit

CMS announces new primary-care payment and health care delivery model

The Centers for Medicare and Medicaid Services (CMS) this week announced a new payment model aimed at transforming and improving how primary care is delivered and paid for in America. The Comprehensive Primary Care Plus (CPC+) model will be implemented in up to 20 regions and can accommodate up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians and the 25 million people they serve. The initiative is designed to provide doctors the freedom to care for their patients the way they think will deliver the best outcomes and to pay them for achieving results and improving care. It builds on the current Comprehensive Primary Care program.

"Strengthening primary care is critical to an effective health care system," said Dr. Patrick Conway, CMS deputy administrator and chief medical officer. "By supporting primary care doctors and clinicians to spend time with patients, serve patients’ needs outside of the office visit, and better coordinate care with specialists we can continue to build a health care system that results in healthier people and smarter spending of our health care dollars. The Comprehensive Primary Care Plus model represents the future of health care that we’re striving towards."

The program is a five-year program that will begin in January 2017. It may also qualify as an alternative payment model under MACRA beginning in 2019.

According to CMS, clinicians will be able to participate in two ways. In Track 1, clinicians will receive a monthly care management fee for specific services. That fee is in addition to the fee-for-service payments under the Medicare Physician Fee Schedule for care.

Track 2, is a hybrid payment design that will allow practices to receive payment for monthly care management and, instead of full Medicare fee-for-service payments for evaluation and management services, they will receive reduced Medicare fee-for-service payments and up-front bundled comprehensive primary-care payments. This plan will allow greater flexibility in how practices deliver care outside of the traditional face-to-face encounter, the agency said.

Physicians in both tracks can receive upfront incentive payments that they might have to repay if they do not perform well on quality and utilization metrics. Payment reductions for poor performers could be as high as 14 percent.

"At first glance, this new payment model initiative includes several advances over the current primary care model, particularly because it emphasizes improvements in care that are achievable by primary care physicians instead of cost reductions that are beyond their control," said Dr. Steven J. Stack, M.D., president of the American Medical Association.

"We look forward to reviewing the proposal in detail and working constructively with CMS to ensure physicians have flexible and workable payment models that support high-quality patient care and put less administrative burden on physician practices to alleviate physician burnout."

CMS is expected to announce the CPC+ regions in July.

For questions about the payment model and solicitation process, please visit the Comprehensive Primary Care Plus web page or email

CMS is also hosting two webinars about the initiative open to all interested stakeholders.  To register, click on the links below.

Thursday, April 14, 3 - 4 p.m. EDT
Tuesday, April 19  |  3 - 4p.m. EDT

CMS announces second cycle of Medicare revalidation

Since the passage of the Affordable Care Act (ACA), all Medicare providers and suppliers have been required to revalidate their Medicare enrollment information under new enrollment screening criteria in an effort to prevent fraud within the Medicare system. Once a Medicare enrollment application is validated, the clock starts ticking on a five-year revalidation cycle. Now that five years have passed since the ACA's revalidation requirement took effect, the Centers for Medicare and Medicaid Services (CMS) is initiating a second cycle of revalidation requests.

According to CMS, Medicare Administrative Contractors (MAC) – Noridian in California – will continue to send revalidation notices two or three months prior to each provider’s revalidation due date.

What providers need to know:

  • If you have multiple reassignments/billing structures, you must coordinate the revalidation application submission with each entity.

  • MACs will send revalidation notices (either by email or mail) two or three months prior to the revalidation due date. When responding to revalidation requests, be sure to revalidate your entire Medicare enrollment record, including all reassignment and practice locations.

  • If a revalidation application is received but incomplete, your MAC will contact you for the missing information. If the missing information is not received within 30 days of the request, the MAC will deactivate your billing privileges.

  • If billing privileges are deactivated, a reactivation will result in the same Provider Transaction Access Number, but there will be an interruption in billing during the period of deactivation. This will result in a gap in the provider’s enrollment status with Medicare.

  • If the revalidation application is approved, the provider will be revalidated and no further action is needed.
Providers can now look up an individual provider or organization to find their revalidation date through CMS’ look-up tool. Those due for revalidation in the near future will display a revalidation due date. All other providers/suppliers will see "TBD" in the due date field.

For more information on the revalidation process, see MLN Matters #SE1605.

If you have questions about the revalidation process, click here or contact Noridian by calling (855) 609-9960.

Deadline to file for meaningful use hardship exemption is March 15

In mid-December, Congress adopted a last-minute bill that gives CMS the authority to grant a blanket exemption for all eligible physicians who apply for the exemption from the 2015 meaningful use penalties. This action prevents the Centers for Medicare and Medicaid Services (CMS) from implementing Medicare payment penalties for physicians who fail to demonstrate meaningful use of a certified electronic health record (EHR) system in 2015.

New rules released last year state that eligible professionals must attest that they met the requirements for stage 2 meaningful use for a period of 90 consecutive days during calendar year 2015. However, CMS did not publish the updated regulations for stage 2 meaningful use until October 16, 2015. As a result, eligible professionals were not able to report until fewer than the 90 required days remained in the calendar year.

CMS had previously stated that it would grant hardship exemptions for 2015 if providers were unable to attest due to the late publishing of the rule, but law at that time only authorized it to grant such exemptions on a case-by-case basis. This new law grants CMS the authority to make an automatic exemption IF it receives a hardship exemption application. It also streamlines the exemption process, alleviating burdensome administrative issues for both physicians and the agency.

Under the new law, physicians are still required to file for a hardship exemption to avoid a payment adjustment for 2015 no later than March 15, 2016.  CMA has just published a new resource titled, "Meaningful Use Hardship Exception Frequently Asked Questions" available FREE for CMA members at (top of the page) and is also available in the CMA resource library. The resource is not available to non-members.

Physicians are urged to preemptively file for a 2015 hardship exception to avoid penalties in 2017. Physicians are encouraged to apply even if they are uncertain whether they will meet the program requirements this year. CMS has stated that it will broadly accept hardship exemptions because of the delayed publication of the program regulations. Applying for the hardship will not prevent a physician from earning an incentive; it simply protects a physician from receiving a meaningful use penalty. Therefore, physicians who believe that they met the meaningful use requirements for the 2015 reporting period should still apply for the hardship protection. Note that the program operates on a two-year look-back period, meaning that physicians who are granted an exception for the 2015 program will avoid a financial penalty for 2017.

The application is available on the CMS website and can be downloaded by clicking here. Physicians are encouraged to apply for a hardship under the “EHR Certification/Vendor Issues (CEHRT Issues)” category (option 2.2.d in the application). The American Medical Association (AMA) has published a fact sheet that includes step-by-step instructions on how to apply for the hardship exemption.

The deadlines for submitting applications for hardship exceptions are:

  • Eligible physicians: March 15, 2016
  • Eligible hospitals: April 1, 2016
CMA and AMA worked frantically the last few weeks of 2015 to get the bill passed authorizing this blanket exemption. CMA extends a huge thank you to Majority Leader Kevin McCarthy (R-CA) and Minority Leader Nancy Pelosi (D-CA) for agreeing to keep the House in session and pass the bill on unanimous consent.

For more information on the EHR incentive program, see the CMS tipsheet, "EHR Incentive Programs for Eligible Professionals: What You Need to Know for 2015."

CMS to hold webinars for providers on updates to the Physician Compare website

The Centers for Medicare and Medicaid Services (CMS) will host a series of one-hour webinars about recent updates to the Physician Compare website and future plans for public reporting, including benchmark and star ratings.

The Affordable Care Act required CMS to create a website that would allow consumers to search for and compare physicians and other health care professionals who provide Medicare services. That site—the "Physician Compare" website, initially launched in 2010—provides contact information, specialties and clinical training, hospital affiliations, and group practice information.

In 2014, the website also began phasing in physician quality data from the Physician Quality Reporting System, including the Group Practice Reporting Option, the Electronic Prescribing Incentive Program and the Electronic Health Record Meaningful Use Program.

During each webinar, the Physician Compare Support Team will present information and then address participant questions. All sessions will present the same information.

Webinars will be conducted via WebEx at the following times:

  • Tuesday, February 23, 2016, at 9 a.m.
  • Wednesday, February 24, 2016, at 1 p.m.
  • Thursday, February 25, 2016, at 8 a.m.
To register, click here.

For more information about the Physician Compare Initiative, click here.

Noridian posts updated Medicare Physician Fee Schedule

California's Medicare contractor, Noridian, has posted an updated 2016 Medicare Physician Fee Schedule on its website. Last week, Noridian had removed the fee schedule because it contained several technical errors that needed to be fixed.

This update is not expected to cause any delays in reimbursement for physicians, because under current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt.

The updated fees are valid for dates of service from January 1 through December 31, 2016.

To see the updated fee schedule, click here.

Contact: Cheryl Bradley, (213) 226-0338 or

AMA publishes guide to physician-focused alternative payment models

The legislation that repealed the Medicare sustainable growth rate—the Medicare Access and CHIP Reauthorization Act (MACRA)—created major new opportunities to advance alternative payment models (APM). Starting in 2019, MACRA will provide a 5 percent annual bonus payment to physicians who participate in APMs and it exempts them from participating in the fee-for-service meaningful use and quality reporting programs (MACRA's Merit-Based Incentive Payment System).

In addition to accountable care organizations, medical homes and bundled payments for hospital-based episodes, MACRA also provides for the development of “physician-focused” APMs. The American Medical Association (AMA) worked with Harold Miller at the Center for Healthcare Quality and Payment Reform to develop a “Guide to Physician-Focused Alternative Payment Models,” which describes seven different APMs that can help physicians in every specialty redesign the way they deliver care in order to improve patient care, manage health care spending and qualify for APM annual bonus payments. The seven APMs include:

  1. Payment for a High-Value Service
  2. Condition-Based Payment for Physician Services
  3. Multi-Physician Bundled Payment
  4. Physician-Facility Procedure Bundle
  5. Warrantied Payment for Physician Services
  6. Episode Payment for a Procedure
  7. Condition-Based Payment

The seven APMs described in the guide have been designed to be able to meet the MACRA eligibility criteria for APMs; however, this will require validation from the Centers for Medicare and Medicaid Services in the future rulemaking process. Under each APM, physicians would take accountability for specific aspects of spending and quality they can control or influence. Physicians will be required to accept some downside financial risk. However, unlike many APMs that have been implemented to date, the physician-focused APMs would not place physicians at financial risk for costs they cannot control.

Importantly, each of the APMs in this report would give participating physicians the resources and flexibility they need to redesign care systems so they can successfully improve care and manage spending for the particular patients, conditions and episodes for which they would be accountable.

In addition to describing the APM designs, the guide also provides examples of how the APMs are being used by different specialties and how they could be applied to diverse patient populations, including cancer care, cardiovascular care, chronic disease management, emergency medicine, gastroenterology, maternity care and surgery.

Click here for more information.

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


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