John Holcomb, MD, a San Antonio pulmonologist and chair of TMA's Select Committee on Medicaid, CHIP, and the Uninsured, testified at the Sunset Advisory Commission last month on proposed changes to the Texas Health and Human Services Commission (HHSC). On behalf of TMA and four other organizations, Dr. Holcomb testified on concerns with Medicaid HMOs and the HHSC Office of Inspector General (OIG). Comments touched on public health matters, as well.
TMA supports sunset recommendations that would further strengthen oversight of Medicaid HMOs and streamline and simplify Medicaid HMO paperwork requirements.
"The expansion of Medicaid HMOs over the past decade corresponds to a simultaneous decline in physician Medicaid participation. When TMA surveys physicians about why they are limiting or leaving Medicaid, the second and third most-cited reasons — after inadequate payments — are mountainous paperwork and convoluted prior authorization requirements, which together are a stranglehold on physicians' willingness to see Medicaid patients. To attract and retain Medicaid participating physicians, Texas must reduce what it costs physicians to participate," Dr. Holcomb said.
In testimony related to OIG's Medicaid fraud and abuse investigations, Dr. Holcomb said "the Sunset staff recommendations build on positive changes the legislature enacted in 2013 to direct the Office of Inspector General to establish fairer investigations."
A 225-page report on HHSC by the Texas Sunset Advisory Commission says the state's use of freezing payments to physicians suspected of possible Medicaid fraud "has gone beyond the law's intent." The report describes the HHSC Office of Inspector General (OIG) as an agency with poorly trained staff and little accountability or transparency.
TMA has long championed improvements in the Medicaid system and in OIG's investigations of physicians accused of fraud, waste, and abuse. In comments submitted to the commission, Dr. Holcomb iterated TMA's support for the commission's recommendations "to improve the efficiency and effectiveness of OIG's administrative and investigative processes" and to "clarify OIG's payment hold authority and streamline the CAF [credible allegation of fraud] hold hearing process."
In the comments, TMA outlines its support for the report's recommendations to:
- Have a fair administrative process designed to define, detect, and prevent fraudulent and abusive conduct that wastes taxpayer funds;
- Improve the efficiency of the investigation process, reserve CAF holds for serious situations to mitigate ongoing financial risk to the state, and streamline the administrative appeal hearing process;
- Include the expertise of medical practitioners with appropriate training and experience in investigations concerning the practice of medicine;
- Implement quality assurance reviews and consistency in investigations;
- Clarify organizational oversight and accountability in an effort to ensure OIG is efficiently and effectively accomplishing its mission to combat fraud, waste, and abuse;
- Better clarify the roles and responsibilities among and between OIG, managed care organizations, and special investigative units; and
- Require OIG to pay the full hearing costs for CAF hold appeals at the State Office of Administrative Hearings (SOAH).
TMA and nine other organizations also penned their strong opposition to a proposed 8-percent reduction in Medicaid payments to advanced practice registered nurses (APRNs) and physician assistants (PAs) practicing in a team-based setting. That's the crux of a letter the organizations sent to HHSC last month. The 2013 legislature instructed HHSC to make the reduction as one of many Medicaid cost-containment initiatives. HHSC estimates the change will save more than $14 million.
TMA and the signatories to the letter tried to stop the measure during the last session to no avail. TMA has been getting phone calls from physicians about the impending cut.
In the letter, TMA President Austin King, MD, and the others say the 8-percent cut "will undermine Medicaid's efforts to recruit and retain not only these providers, but also physicians seeking to practice in team settings," adding a request that "any such proposal consider the practical impact on team-based practices that voluntarily participate in the Medicaid program and the patients they serve."
The proposed rules state an APRN or PA will be paid 100 percent of the physician fee schedule when the supervising physician "made a decision regarding the patient's care or treatment during the billable medical visit." TMA objects to the phrase "during the billable medical visit" because it "seems to preclude scenarios where the APRN/PA sees the patient, develops/revises a plan of care, then subsequently discusses it with the supervising physician."
"In such a scenario, the APRN or PA would follow up with the patient after consulting with the supervising physician. As we interpret the proposed rules, the APRN or PA would not be paid 100 percent of the physician fee schedule in this scenario because the consultation did not occur 'during the billable medical visit,'" the letter states.
TMA recommends deleting that phrase "so that team-based practices have more flexibility as to when the supervising physician and APRN/PA can confer." HHSC partially agreed with the recommendation, agreeing to revise the rules to allow the supervising physician to make a documented decision the same date as the billable medical visit.
The letter concludes by stating "exacting an 8-percent payment cut for clinicians at the forefront of redesigning Texas' Medicaid delivery model will stymie practice innovation and ultimately hinder Medicaid HMO efforts to partner with their network providers to implement new models of care."
The new rules will take effect Jan. 1, 2015. HHSC agreed to postpone enforcement until Feb. 1, 2015, to give practices time to update their systems. If the supervising physician did not engage in decisionmaking regarding the patient's care in accordance with the rules, the claims must be submitted with the APRN's or PA's provider identifier or under the physician's number with the appropriate modifier to indicate who provided the care.
Additional details will be posted on the Texas Medicaid and Healthcare Partnership website in December.
Action, Dec. 1, 2014
TMA is hearing from physicians who are being audited for meaningful use and some who have had their meaningful use incentive dollars recouped. Don't let this happen to you. Remember: Meaningful use is all or nothing. Physicians must meet all measures for successful attestation. This includes conducting a security risk analysis for HIPAA to ensure protection of patient information.
The Centers for Medicare & Medicaid Services (CMS) has indicated about 6 percent of those receiving incentive payments will be audited. If a physician fails an audit and continues to participate, the audits continue before CMS makes another payment. Anyone who receives the incentives could be audited, and recipients should retain all supporting documentation for six years.
TMA has these recommendations to help practices:
- Take screen shots of electronic health record (EHR) reports indicating you met a meaningful use measure. If you try to re-create a report at a later date, the EHR may return a different result.
- When the meaningful use criteria specify "more than," that doesn't mean "equal to." For example, if the criteria indicate you need to record demographics for more than 80 percent of your patients, then your denominator and numerator should be such that they don't total 80 percent. They must be more.
- Keep a meaningful use file (paper or electronic) with all documentation, and know where that file is. Staff turnover could mean the person who created the file is no longer working for you when the audit request comes.
The Garden City, N.Y., accounting firm Figliozzi & Co. is conducting the audits for CMS. The firm is sending letters asking for documentation supporting the meaningful use attestation. Figliozzi seeks these types of data:
- Documentation showing use of a certified EHR system for meaningful use attestation;
- Documentation showing completion of the attestation for the core set of meaningful use criteria; and
- Documentation showing completion of the required number of menu set meaningful use objectives.
Physicians and others selected for the audits have two weeks to submit their documentation. The audits don't involve site visits. If physicians are ineligible for payment, they may file an appeal through CMS.
For questions about audits, the incentive program, and other health information technology matters, contact TMA's Department of Health Information Technology at (800) 880-5720 or by email.
Action, Dec. 1, 2014
According to the Centers for Medicare & Medicaid Services (CMS), physicians who are beyond their first year of participation in the Medicare electronic health record (EHR) incentive program have the option to streamline their reporting efforts and report quality data only once for several Medicare quality programs.
In 2014, physicians may submit data one time and receive credit for several Medicare quality programs. Depending on eligibility, physicians and group practices may report on a single set of clinical quality measures (CQMs) as required by meaningful use and satisfy the requirements for:
- Physician Quality Reporting System (PQRS),
- Value-based payment modifier (VM),
- Medicare EHR incentive program,
- Medicare shared savings program accountable care organization (ACO),
- Pioneer ACO, and
- Comprehensive Primary Care Initiative (CPCI).
Physicians should contact their EHR vendors to discuss this reporting option. To receive credit for these programs, physicians must submit data from Jan. 1 through Dec. 31, 2014. The deadline for submission is Feb. 28, 2015. The CMS website has details about CQMs, including a complete list of the 64 measures and their respective National Quality Strategy domain.
Physicians who choose to use this method will earn the 2014 PQRS bonus payment and avoid the 2016 PQRS penalty. Physicians also will satisfy the CQM requirements for the other programs, if eligible.
CMS provides these resources to help you learn how to report data one time for the 2014 program year:
For more information about the Medicare EHR incentive program, contact the CMS Electronic Health Record Information Center by phone, (888) 734-6433, or visit the CMS website. You can also contact the TMA Knowledge Center by phone, (800) 880-7955, or email.
Action, Dec. 1, 2014