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 TMA Action March 16, 2015   News and Insights from Texas Medical Association

 

INSIDE:  TMA Asks Feds to Avert ICD-10 Calamity

New, Under-the-Radar Government Audits Surface
CMS Rebuffs TMA's Request to Drop Coercive MU Measures
TMA Asks Feds to Avert ICD-10 Calamity
Toolkit for Physicians Facing Medical Audits
Dual Eligible Pilot Enrollment Starts April 1
Come to TexMed 2015 — FREE for All TMA Members!
One Stone, Two Renewals

TMA Foundation Thanks 19 New $10K+ Super Donors
Youth Fitness Programs Receive TMA Foundation's Highest Award
Save the Date(s) for First Tuesdays
This Month in Texas Medicine
Tax Relief, Medicaid Primary Care Pay Bump in Sight; Scope in Crosshairs
Are HIEs Valuable?
 
 

New, Under-the-Radar Government Audits Surface


The Centers for Medicare & Medicaid Services (CMS) has started an audit of the Physician Quality Reporting System (PQRS) and Electronic Prescribing Incentive (eRx) programs through an IT company called Arch Systems, based in Maryland. 

The first report of the curiously unheralded audit surfaced last month when a Dallas physician called TMA after she received a notification letter from Arch. In a four-page letter that included a process flowchart, Arch called the audit a "measure-specific validation of the program" and explained each step of the audit process, which would begin with a phone meeting and continue later with a review of up to 30 patient charts. 

CMS calls the audit a survey, which is conducted under the Data Assessment, Accuracy, and Improper Payments Identification Support project. The project is designed to identify sources of improper payments due to intentional fraud or unintentional error. The PQRS and eRx programs will be evaluated for accuracy and to identify – and eventually recover – improper payments. Participation is considered voluntary, but if you choose not to participate, Arch will inform CMS of your unwillingness to provide requested information. The data is collected by telephone, fax, and email. Arch will conduct these audits through 2017. Additionally, based on the project's results, recommendations will be made so that CMS can avoid future data integrity issues.

For more information, contact the CMS QualityNet Help Desk, Monday through Friday, 7 am to 7 pm CT, by phone, (866) 288-8912, or by email; or contact Arch Systems, by phone, (410) 277-9782, or by email. You also can contact the TMA Knowledge Center by phone, (800) 880-7955, or email.

Action, March 16, 2015

TMA Practice E-Tips main page


CMS Rebuffs TMA's Request to Drop Coercive MU Measures


The size of your next Medicare check could very well rest on whether you can get enough of your patients to email you; federal regulators believe that's a sensible way to evaluate your meaningful use (MU) progress. In fact, if you can't get more than 5 percent of your patients to send a "secure message using certified electronic health record technology (CEHRT)," you'll not only lose eligibility for incentive pay, you'll also be penalized. 

Last November, TMA President Austin King, MD, asked the Centers for Medicare & Medicaid (CMS) to drop three measures in its Medicare electronic health record (EHR) incentive program that have nothing to do with clinical care or outcomes and over which physicians have no control. CMS said no. 

In her response to Dr. King's request, then-CMS Administrator Marilyn Tavenner agreed that the measures aren't easy. 

"We recognized the increased challenges associated with the patient engagement objective and its associated measures," she said. "Therefore, we established a low threshold for these measures, recognizing that some measures under this objective require some direct action by the patient." 

At issue are the measurements used in the program's Stage 2 core objectives numbers 7 and 17, which are designed to encourage electronic interaction between physicians and patients. During a 90-day reporting period, physicians who are enrolled in the program must somehow show that more than 5 percent of their patients used the EHR either to look at their medical record online or download or send them to a third party. Another measure requires physicians to get more than 5 percent of their patients to send some kind of secure electronic message. 

There's no grading scale or bell curve applied in the Stage 2 assessment. You must achieve all 22 measures that make up the 17 objectives to qualify for incentive payments. Miss the mark on even one measure, and you're not only disqualified for incentives but also slapped with a payment penalty.

It's an unacceptable all-or-nothing approach, according to Dr. King, and it has no bearing on clinical outcomes. In his letter to Ms. Tavenner, Dr. King said that without evidence showing it improves outcomes, it's unreasonable for CMS to base financial incentives or penalties on a physician's ability to engineer patients' online communication behavior. 

"Many physicians treat elderly patient populations, and it is not reasonable to expect these patients to have access to a computer and the Internet to download or transmit information, much less the desire to do so," Dr. King said. "If CMS desires patients to behave a certain way, the incentives should be for those patients. It should not be required of physicians."

The objectives can be especially onerous for physicians who see higher numbers of Medicare patients, 83 percent of whom are older than 65 years and 40 percent of whom are 75 or older, which is a demographic that is least likely to adopt technology. A 2012 Pew study showed that of persons aged 65 and older, 41 percent do not use the Internet at all, 53 percent do not have broadband access at home, and 23 percent do not use cellphones; starting at age 75, Internet use begins to drop significantly.

Dr. King had also asked that CMS work with Congress to suspend all MU physician penalties set to begin Jan. 1, 2015. "Physicians should not be penalized for not meeting virtually unattainable meaningful use measures," Dr. King said. "The unintended consequence will be reduction in Medicare patients' much needed access to care."

In her reply, Ms. Tavenner said that because the penalties were established by statute, any changes must originate from Congress. "Further, we generally cannot suspend the current measures and objectives without notice and comment rulemaking," Ms. Tavenner said. "Therefore, we cannot accommodate such requests."

For more Medicare EHR incentive program information, visit TMA's Medicare Resource page. For help with Medicare payment issues, email TMA Payment Advocacy, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems. Also, visit the TMA Payment Advocacy Services webpage and TMA's Payer page for more resources and information.

Action, March 16, 2015


TMA Asks Feds to Avert ICD-10 Calamity


Describing the Oct. 1 mandatory transition to ICD-10 as a "potential calamity," Texas Medical Association President Austin King, MD, asked the Centers for Medicare & Medicaid Services (CMS) to consider some moves that would make the transition less risky for physicians and patients. 

Because many physician practices simply aren't ready for it, Dr. King said, the transition could spell disaster and would "disrupt hundreds of thousands of physician practices across the country and threaten the patients who depend on us for care." A recent poll showed just 21 percent of physician practices surveyed say they're on track to be ready Oct. 1.

CMS has completed three rounds of end-to-end ICD-10 testing and reported acceptance rates of 89 percent (March 2014), 76 percent (November 2014), and 81 percent (February 2015). And while the results show most rejected claims were not ICD-10 related errors but errors submitters made, Dr. King said in his March 11 letter, they still indicate serious problems.

"It is reasonable to assume that all of those participating in the testing believed they were prepared for the ICD-10 transition," Dr. King said, "And at least some of those test claims that were accepted likely would have been rejected further down the line for errors unrelated to the acceptance process."

Dr. King expressed particular concern for the readiness of small practices, such as the 63 percent of Texas physicians who are solo practitioners or who practice in groups of three or fewer. In his letter, he outlined three specific requests for CMS consideration:  

  1. Permit a concurrent transition, allowing for the use of either ICD-9 or ICD-10 for a period of two years following the Oct. 1, 2015, implementation date;
  2. Provide a safe haven period during this two-year transition during which physicians will not be penalized for the errors, mistakes, and/or malfunctions that are certain to occur during that transition period; and
  3. Require all electronic health record, practice management, and billing companies to complete all software upgrades no less than three months in advance of the Oct. 1 transition date. Current rules only require that the upgrades be ready by that date. It is imperative that properly functioning software be installed in physician offices with sufficient time to allow proper testing and subsequent adjustments.   

For more practice help on ICD-10, visit TMA's ICD-10 Resource Center

Action, March 16, 2015


Toolkit for Physicians Facing Medical Audits


A pair of upcoming webinars show you how to survive a medical audit and offer tips on preventing an audit in the first place.

The Physicians Advocacy Institute, Inc. (PAI) and the American College of Emergency Physicians (ACEP) will host the seminars, called "Top Ten Tips for Physicians Facing RAC and Other Medical Audits." The webinars will expand on the PAI and ACEP's collaborative project, Toolkit for Physicians Facing Medical Audits, which is available on PAI's website.

The dates for the upcoming webinars, both of which will cover the same information, are:

  • Thursday, March 19, noon-1 pm, CDT. Register here.
  • Wednesday, April 1, 10-11 am, CDT. Register here.

For questions, email Kelly Kenney.

Action, March 16, 2015


   TMAIT Action Ad Sept 14       


 

Dual Eligible Pilot Enrollment Starts April 1


Patient enrollment in the Texas Health and Human Services Commission's (HHSC's) six-county Dual Eligibles Integrated Care Demonstration Project begins April 1. The project is a partnership between Texas and the Centers for Medicare & Medicaid Services (CMS) to test a new model for providing coordinated care to patients enrolled in both Medicare and Medicaid. Texas and CMS will contract with Medicare and Medicaid managed care plans to coordinate patient care across both programs.

Nationally, more than 9.6 million seniors and people with significant disabilities are dually eligible for both programs, and as many as 2 million of them may be included in the demonstrations. Often, medically fragile, dual-eligible patients are typically poorer and sicker than other Medicare beneficiaries and use more health care services. 

The project's objectives include:

  • Making it easier for clients to get care,
  • Promoting independence in the community,
  • Eliminating cost shifting between Medicare and Medicaid, and
  • Achieving cost savings for the state and federal government through improvements in care and coordination. 

More than 165,000 Texas patients in Bexar, Dallas, El Paso, Harris, Hidalgo, and Tarrant counties qualify for the program and may eventually be covered under the new plan; only patients who opted into the program will be enrolled in March.

Patients will be included in the project if they: 

  • Are age 21 or older;
  • Get Medicare Parts A, B, and D, and are receiving full Medicaid benefits; and
  • Are in the Medicaid STAR+PLUS program, which serves Medicaid clients who have disabilities or get STAR+PLUS Home and Community Based Services waiver services.  

In the demonstration, health plans must provide the full array of Medicaid and Medicare services. This includes any benefits that will be added to the STAR+PLUS service array by March 1, such as nursing facility services, psychosocial mental health rehabilitation, and targeted case management. 

Passive enrollment will begin in April and progress incrementally through August and will apply to 20 percent of nonfacility patients within a county by ZIP code. For example, all dual eligible patients eligible for passive enrollment who live in a pilot county and who are in cohort 1 ZIP codes (see list), will be passively enrolled on April 1 unless they opted out. Enrollment of dual-eligible nursing facility patients will begin Aug. 1 in Bexar and El Paso counties, followed by Harris County nursing facility patients on Sept. 1 and those in remaining counties on Oct. 1.

HHSC has developed a detailed enrollment grid by county to help practices better understand how patients will be assigned to a plan.

Patients may elect to opt out before the pilot begins. If a patient opts out after being enrolled in a plan, then the change will take effect the first of the following month. Physicians cannot steer patients to a particular managed care plan, but can inform patients about the demonstration plan(s), if any, in which they participate. Patients who opt out may also later opt back in.

Patients Still Have a Choice

Patients eligible for the demonstration will be sent introduction letters 90 days before enrollment and additional reminder letters 60 days and 30 days before passive enrollment begins. If a patient is enrolled in a plan whose network does not include their physician(s), continuity of care must be protected for the first 90 days. 

Specifically, the contract between CMS, HHSC, and the plans specifies that a patient's care must not be disrupted when the patient enrolls in a plan: "The STAR+PLUS Medicare and Medicaid Plan (MMP) allows enrollees receiving any services at the time of enrollment to maintain their current providers, including with providers who are not part of the STAR+PLUS MMP's network, and service authorizations, including drugs, for at least up to ninety (90) days after the enrollee's enrollment effective date or until the Plan of Care and/or ISP are updated and agreed to by the enrollee, whichever is earlier."

The contract further states that the STAR+PLUS MMP must ensure continuity of care for new enrollees whose health or behavioral health condition has been treated by specialty care providers or whose health could be placed in jeopardy if medically necessary covered services are disrupted or interrupted.

Visit the HHSC or CMS websites for more information about the project, including the Texas proposal and memorandum of understanding.

To see how CMS will be monitor and evaluate the Texas demonstration project, read Measurement, Monitoring, and Evaluation of State Demonstrations to Integrate Care for Dual Eligible Individuals.

HHSC website resources include: 

Training Webinar Archive:

Texas Dual-Eligibles Integrated Care Demonstration Project, Jan. 21, 2015 
You must register with Citrix to view this archive. To learn about this archive in other formats, email Heather Kuhlman at HHSC. 

Action, March 16, 2015

Come to TexMed 2015 — FREE for All TMA Members!


Register today for TMA's free annual conference, and join thousands of fellow Texas physicians, as TexMed 2015 arrives in Austin May 1-2 for a weekend of advocacy, education, and collaboration. 

TexMed is TMA's largest event of the year, offering free continuing medical education (CME), an extensive gathering of exhibitors to help with every aspect of your practice, and, because we're in Austin, a special Thursday event at the Capitol.

See all the event details and register online.

Now Accepting Quality Poster Submissions

The latest in your colleagues' quality improvement initiatives will be on display during the third annual TexMed Poster Session in an author-hosted walk-through on Saturday from 8 am to 9 am. Categories have been expanded this year to offer physicians and medical practice staff more opportunities to participate. For additional information or to submit your own application to participate, visit the poster session webpage

For a full schedule of TexMed 2015 events, CME, exhibitors, lodging information, fun things to do in and around Austin, and how to get more involved in TMA policy creation, visit the TMA website. Be sure to register today to reserve your spot to enjoy this free benefit of your TMA membership.

Action, March 16, 2015


One Stone, Two Renewals


Now, Texas physicians can renew their controlled substances registration (CSR) permit online when they renew their medical license on the Texas Medical Board (TMB) website.

If you already have a CSR permit that just needs to be renewed, you no longer have to go through the Department of Public Safety (DPS).

Thanks to TMA advocacy in the last legislative session, a CSR permit lasts two years instead of one, and you can now renew your CSR on the TMB website the next time you renew your medical license. That will give the permit and your license the same expiration date.

Before renewing either, check the DPS website to see when your CSR expires. If it has the same expiration date as your medical license, you should renew both on the TMB website for quicker service.

Action, March 16, 2015



 TMLT Action Ad 4.13 


 

TMA Foundation Thanks 19 New $10K+ Super Donors


The TMA Foundation honored 19 special donors at TMA's Winter Conference in January for having donated at least $10,000 each to attain the foundation's Major Donor status in 2014. 

Persons become Major Donors when their cumulative giving reaches the $10,000 value, and TMAF recognizes them in various ways, including listings in TMA publications and permanent tribute on commemorative walls at TMA's headquarters in Austin. More than 175 persons have reached the level since 1990.

TMAF is the 501 (c)(3) charitable arm of TMA dedicated to connecting physicians' charitable concerns with the people of Texas. For more information or to donate, visit the TMAF website.

Action, March 16, 2015


Youth Fitness Programs Receive TMA Foundation's Highest Award


The TMA Foundation (TMAF) presented its highest prize, the John P. McGovern Champion of Health (COH) Award, to FitWorth, a program launched by Fort Worth Mayor Betsy Price in 2012 to combat childhood obesity. The award recognizes exceptional projects that address urgent public health threats and further TMAF's mission to help physicians create a healthier future for all Texans. 

The secondary COH Award went to the Medical Miles Mentor (MMM) program run by the TMA Medical Student Chapter of the Baylor College of Medicine. Created in 2012, MMM improves the health and wellness of sixth-graders at Cullen Middle School through physical activity and mentoring. More than 90 percent of the school's students are economically disadvantaged, and 34 percent live below the poverty line.

The top COH winner receives $5,000 and a specially commissioned bronze statue, and the secondary honoree receives $2,500. The award is named after John P. McGovern, MD, a philanthropist, scholar, and noted allergist who founded the John P. McGovern Foundation in Houston. Dr. McGovern established a permanent endowment at TMAF, which supports the award. Learn more about TMAF and its COH award on the TMAF website.

Action, March 16, 2015


Save the Date(s) for First Tuesdays


First Tuesdays at the Capitol has returned, and the Family of Medicine needs you to be there.

The "White Coat Invasion" has been the key to physicians' successes in the Texas Legislature since the inception of First Tuesdays at the Capitol in 2003. Our senators and representatives listen when their hometown doctors appear in their offices. Our influence is so much greater when physicians and alliance members arrive en masse in the House and Senate galleries. It's time again to bring out Texas medicine's strongest weapon.

Mark your calendar for the remaining 2015 First Tuesdays at the Capitol, and register today:

  • April 7 and
  • May 5.

Although the Texas Legislature is becoming more hyper-partisan and hyper-political, TMA will continue to work for what's best for patients and their physicians. Medicine's 2015 legislative agenda, based on TMA's Healthy Vision 2020, Second Edition, will focus on:

  • Increasing funding for graduate medical education.
  • Improving physicians' Medicaid and CHIP payments to more appropriately reflect the services they provide to patients.
  • Holding health insurance companies accountable for creating and promoting adequate physician networks.
  • Devising and enacting a system for providing health care to low-income Texans that improves efficiencies by reducing bureaucracy and paperwork.
  • Stopping any efforts to expand scope of practice beyond that safely permitted by nonphysician practitioners' education, training, and skills.
  • Promoting government efficiency and accountability by reducing Medicaid red tape.
  • Protecting physicians' ability to charge for their services.
  • Improving the state's public health defense to better respond in a crisis.
  • Preserving Texas' landmark medical liability reforms.
  • Protecting the patient-physician relationship from corporate intrusions.

Action, March 16, 2015



  PC Action Ad Aug 13   


 

This Month in Texas Medicine


The April issue of Texas Medicine guides you through the what, when, why, and how behind Medicare value-based care; examines the educational and workforce benefits of resident moonlighting; discusses a Texas court case in which the telehealth provider Teladoc argues that a face-to-face meeting is unnecessary for new patients; explains the proposed health service enterprise gateway, which would connect to local health information exchanges and give physicians a single place to exchange data with all state health agencies; and introduces Ira Byock, MD, who will speak at TexMed's General Session in May about providing the best care possible at the end of life. 


Click to launch the full edition in a new window.   

Texas Medicine RSS Feed

Don't want to wait for Texas Medicine to land in your mailbox? You can access it as an RSS feed, the same way you get the TMA Practice E-Tips RSS feed.


E-Tips RSS Feed

TMA Practice E-Tips, a valuable source of hands-on, use-it-now advice on coding, billing, payment, HIPAA compliance, office policies and procedures, and practice marketing, is available as an RSS feed on the TMA website. Once there, you can download an RSS reader, such as Feedreader, Sharpreader, Sage, or NetNewsWire Lite. You also can subscribe to the RSS feeds for TMA news releases and for Blogged Arteries, the feed for Action.


Action, April 1, 2015


Tax Relief, Medicaid Primary Care Pay Bump in Sight; Scope in Crosshairs


As hearings get under way and lawmakers scramble to fashion a budget at the halfway mark of the 2015 legislative session, graduate medical education (GME) funding and tax relief remain a focal point for the legislature, and the House of Medicine has made early progress on both fronts. Lawmakers also heard TMA's call to reinstate the Medicaid-Medicare parity payments for primary care. 

As the bill count climbed toward the filing deadline in mid-March, however, lobbyists remain vigilant of an unprecedented attempt at scope-of-practice expansion by nurse practitioners. Battles brewed over balance billing restrictions and vaccine exemptions that threaten the practice of medicine and patient safety. And TMA prepared to fight an attempt to repeal last session's bill limiting silent PPOs.

GME Boost, Tax Relief in Sight

As the House Appropriations Committee and Senate Finance Committee aim to finalize their respective 2016-17 budgets this month, both chambers' proposals add funding for GME, women's health care, and mental health care services. 

GME stands to get a significant boost: The House and Senate bills add roughly $30 million and $60 million, respectively, to fund residency slot expansions. It will be up to a conference committee to work out the differences. Meanwhile, Senate Bill 18 by Senate Finance Committee Chair Senator Jane Nelson (R-Flower Mound) and Sens. Juan "Chuy" Hinojosa (D-McAllen) and Kel Seliger (R-Amarillo) proposes a set of GME expansion programs that would put that budget money into action to reach a goal of 1.1 slots per medical school graduate. TMA is monitoring the bill to make sure it addresses critical physician shortages across specialties without unnecessarily complicating the GME funding process. 

The draft House budget bill also adds to the Department of State Health Services budget for programs in infectious disease prevention ($20 million); tobacco cessation ($10.7 million); primary care and women's health care ($20 million); and neonatal drug abstinence ($17 million). Senate committee budget deliberations are still under way.

However, leaders in the upper chamber stepped out first with their expected push for a tax relief package. Senator Nelson, Lt. Gov. Dan Patrick, and Sen. Charles Schwertner, MD (R-Georgetown), unveiled a proposal that contains $4.6 billion in property and franchise tax cuts and consists of three bills: Senate bills 1 and 7 by Senator Nelson and Senate Bill 8 by Senator Schwertner. A House proposal is not far behind.

More relief for physicians could be on the way thanks to Sen. Kevin Eltife (R-Tyler), who filed Senate Bill 765 to eliminate the $200 annual occupations tax on physicians and other Texas professions. Physicians are subject to both the franchise tax and the occupations tax, and TMA advocates that the double tax is not appropriate. 

Medicaid Decisions Ahead

As this report went to press, decisions over Medicaid funding — including how to cover $1.4 billion in cost growth and whether to continue paying select primary care physicians at rates that match Medicare — were a work in progress. 

The House Appropriations Committee welcomed and adopted a recommendation by Rep. Four Price (R-Amarillo) to add money to reinstate the Medicaid-Medicare parity payments for primary care starting Sept. 1, 2015. The Affordable Care Act increased the Medicaid primary care payments to Medicare rates for two years using federal funds, but the pay bump expired Dec. 31, 2014. 

At a standstill, however, are state-federal negotiations over increasing access to health coverage for the more than 1 million low-income adults who make too much money to qualify for Texas Medicaid but not enough to qualify for the ACA marketplace premium tax credits. Members of the Senate Health and Human Services Committee joined Lieutenant Governor Patrick in a letter asking the Obama administration for more flexibility in managing the Medicaid program to help Texans in this so-called "coverage gap." Their letter specifically asks for: 

  • Personal accountability requirements, including cost-sharing, missed appointment fees, and health savings accounts;
  • Tailored benefit packages;
  • Work requirements for able-bodied adults;
  • Reduced physician and provider administrative burdens;
  • Asset testing as part of eligibility criteria;
  • Reinstatement of the active renewal process;
  • Customized certification periods;
  • Exemption from the ACA health insurance issuer fee;
  • Exemption from ACA maintenance of effort requirements; and
  • Exemption from hospital presumptive eligibility. 

While the legislature has yet to act on the payment cuts to physicians treating dual-eligible Medicare and Medicaid patients, Senator Schwertner filed Senate Bill 760 to increase oversight of Medicaid HMO network adequacy, which TMA supports.

Meanwhile, TMA staff pour over a 122-page proposal to overhaul the Health and Human Services Commission, which administers the Texas Medicaid program. The plan to reorganize and consolidate the state's health agency was recommended by the state Sunset Advisory Commission. 

Scope Bills Abound

As expected, the March bill filing deadline was met with a long list of potential scope-of-practice infringements on medicine by physical therapists (PTs), chiropractors, optometrists, and advanced practice registered nurses (APRNs). The bills have drawn opposition from TMA and specialty groups, including ophthalmologists and orthopedic surgeons.

While most of the bills would allow independent prescribing of Schedule II drugs — as typically proposed in past sessions — House Bill 1885 by Rep. Cecil Bell (R-Magnolia) also would allow APRNs to render a medical diagnosis, "the most direct threat on the most fundamental aspect of the practice of medicine we've seen," said TMA lobbyist Dan Finch.

Among the other scope bills TMA is watching: 

  • House bills 1185 and 1473, also by Representative Bell, would allow APRNs and physician assistants to independently sign official documents, like birth and death certificates, and handicap placards;
  • House Bill 1263 by Rep. Richard Raymond (D-Laredo) would give PTs direct access to patients without a physician diagnosis and referral warranting the care;
  • House Bill 1413 by Rep. Craig Goldman (R-Fort Worth) would give optometrists the authority to perform some eye surgery; and 
  • House bills 126, 1174, and 1231 would allow chiropractors to issue handicap placards; conduct physicals for school bus drivers; and examine student athletes for concussions.   

TMA also has its eye on end-of-life legislation it says could interfere with physicians' ability to write do-not-resuscitate orders and could create new liability risks. Unlike last session, which saw a comprehensive piece of end-of-life legislation, medicine and lawmakers are tackling the topic piecemeal. So far, TMA supports emerging bills to require hospital ethics committees to adopt a nondiscrimination policy, and to classify artificial nutrition and hydration as ordinary, not extraordinary, care.  

Balance Billing, Vaccine Exemptions Take Stage

Balance billing battles are rearing their head again with consumer groups galvanizing around Rep. John Smithee's (R-Amarillo) introduction of House Bill 1638. TMA has concerns with the legislation as filed because it would prohibit any out-of-network physician from seeking payment from patients for balances their insurance company doesn't cover for emergency services. Instead, the bill requires the noncontracted doctors and health plans to go to arbitration to settle payment.

TMA is countering the effort with a new white paper, "Network Inadequacy and Unfair Discrimination in Insurance," which explains how health plans' limited networks, benefits coverage, and payment structures contribute to outstanding bills patients may receive. House Bill 3085 by Rep. Nicole Collier (D-Tarrant) was filed at TMA's request to address some of the market problems outlined in the white paper, namely inadequate networks and inaccuracies of health plan directories. The bill permits the Office of Public Insurance Counsel (OPIC), along with the Texas Department of Insurance (TDI), to monitor network adequacy across the spectrum of HMO, PPO, and exclusive provider organizations (EPO) insurance products, and to file complaints with TDI about inaccurate health plan directories.  

TMA is analyzing potential legislative alternatives, too. 

For example, TMA supports House Bill 1624 as filed by Representative Smithee, which could help better inform patients of their coverage options and obligations by requiring additional transparency in health plan provider directories. 

If physicians so choose, House Bill 616 by Rep. Greg Bonnen, MD (R-Friendswood), would require health plans to pay a set portion of physicians' out-of-network charges based on a state-certified database of geographic-specific charges, such as FAIRHealth.org. TMA is taking a neutral position on the bill, due to its voluntary nature: TMA lobbyist Patricia Kolodzey clarifies that it gives physicians a choice as to whether they wish to pursue this avenue for claim payment for their out-of-network services. 

Meanwhile, TMA is monitoring insurance coverage provisions in House Bill 21, which could expand access to investigational drugs, biologics, and devices for terminally-ill patients. The issue is taking stage at the federal level, as well.

Also coming in under the wire were a slew of telemedicine bills TMA is following. 

On public health, hearings are under way. While discussions regarding vaccine exemptions got contentious, TMA is working to make sure the heated discussions do not overshadow viable solutions to avoid over-vaccination, reduce state costs, and ease administrative burdens on physicians and families. 

TMA physicians testified in support of one such solution put forth by Rep. Donna Howard (D-Austin) and Rep. J.D. Sheffield, DO (R-Gatesville). House Bill 465 would require patients to opt out of the state immunization registry ImmTrac, rather than opt in, and preserve minors' vaccination records until they turn 21, up from 18. Physicians also told the Senate Health and Human Services Committee that Senate Bill 538 by Senator Schwertner would help improve Texas' emergency response to infectious disease outbreaks. 

A coalition of House Democrats and Republicans laid out a texting-while-driving ban in House Bill 80, which TMA also supported in testimony. The bill passed out of committee with bipartisan support.

Watch as hearings on medicine's issues speed up now that the bill-filing deadline has passed, and keep up through TMA's Legislative Hotline. TMA's First Tuesdays at the Capitol lobbying events are also a way for you to tell legislators all about medicine's agenda. The last two events will be April 7 and May 5. 

Silent PPO Behind-Your-Back Peddling

TMA's previous legislative win now faces repeal.

The hard-won law TMA pushed through the 2013 legislature that makes it harder for PPOs to peddle your services without your say went up for repeal as of March 12, when Sen. Larry Taylor (R-Friendswood) filed bill SB 1231. The current law covers those situations when PPOs contract with you to treat a set number of patients in their network at discounted rates and then sell that discounted in-network rate to whomever they please without telling you. It frequently reaches the point where you can never know which or how many patients you actually have under your PPO network because that's the objective, to cut costs at your expense.

Last legislative session, after almost a decade of effort, TMA shepherded the passage of Senate Bill 822, which squashed the sneaky practice of rental networks/silent PPOs selling or renting physicians' discounted services without their permission. Before SB 822 went into effect in September 2013, such organizations could transfer physicians' discounted rates to other entities without their knowledge or consent and without steering patients to them. 

And while the won statute doesn't outlaw the buying, selling, or leasing of a contract rate, it makes it just a little bit harder for silent PPOs to do it behind your back, because it requires entities to first: 

  • Register with the Texas Department of Insurance (TDI);
  • Give physicians a line-item list of all network products covered by a payment contract and separate, corresponding fee schedules; and
  • Obtain express authority from and provide prior notification to physicians for each line of business.  

It also authorizes TDI to fine companies that don't comply or to revoke their licenses to conduct business. TDI finalized the bill's rules in June 2014.

As reported in Texas Medicine, the bill also makes it easier and cheaper to resolve improper claims because the line-item provision allows physicians to see which fees apply to which networks, specifically HMOs, PPOs, exclusive provider organizations, or Medicare Advantage or Medicaid managed care plans. Companies looking to buy or sell those rates not only must spell out each line of business in physicians' contracts, but also must get physicians' line-item approval. 

Signing a contract with one PPO network means physicians are signing up for several other networks, according to Lee Spangler, TMA's vice president for medical economics, because several major PPO networks kept their individual names after consolidating into one ownership. "Even under SB 822, a company can pass on its negotiated contract rates to any number of its subsidiaries," Mr. Spangler said, "But they may do so only in the lines of business the physician has agreed to. The physician's express agreement by type of insurance business is a major step forward"

One contract may include several lines of business, which is why Mr. Spangler urges physicians to carefully scrutinize network contracts and pay attention to which types of coverage they are joining.

Amy Lynn Sorrel, associate editor of Texas Medicine, prepared this special supplement to Action.


Are HIEs Valuable?


The Workgroup for Electronic Data Interchange (WEDI) wants to know what stakeholders in the health care delivery community think about the current state of health information exchanges (HIEs) and has posted a 12-question online survey to solicit feedback. 

WEDI is a multistakeholder, national nonprofit and a leading authority on health care information technology.

This is a chance for physicians to let their voices be heard and possibly inform federal policy on HIEs, meaningful use, and electronic health records. You can view comprehensive information about HIEs on the 166-page HIE roadmap recently released by the Office of the National Coordinator for Health Information Technology. 

Action, March 16, 2015


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