Rural Texas Physician

Summer 2015

Rural Texas Physician is a quarterly electronic newsletter catering to physicians in the many rural areas of Texas caring for patients and their communities. TMA’s grassroots membership is the strength of the association. For general inquiries or newsletter comments, email


Patient-Physician Relationship Preserved in 2015 Legislative Session

In a 2015 legislative session marked by new state leadership, new money, and big shifts in how Texas’ major health care agencies oversee care delivery, the House of Medicine remained as steady as ever in its mission to ensure physicians can give their patients the best care possible. That resolve paid off in significant victories that largely build on Texas Medical Association’s 2013 legislative successes.   

Important milestones for Texas physicians include:   

  • Another significant expansion of graduate medical education (GME) funding and resident training positions, and more money for women’s health and mental health services;
  • Fairer rules governing Medicaid fraud investigations; 
  • Red-tape reductions, including the elimination of the Texas Department of Public Safety (DPS) Controlled Substances Registration (CSR) permit; 
  • Greater transparency in health plans sold on the federal exchange; and 
  • A tax break for all licensed physicians.   

GME Wins Big; Tax Cuts for All
Despite the constitutional spending limit, lawmakers had an $8 billion surplus to spend, made possible by a steady upswing in sales and oil and gas tax revenues. About half of the surplus ultimately went into a $3.8 billion comprehensive tax relief package; the other half was interspersed among education, health care, transportation, and border security needs.

Other than losing a Medicaid-Medicare parity payment increase, TMA lobbyists say the tax relief package did not cut into medicine’s budget priorities. House Bill 1 spends roughly $210 billion in state and federal money. The 2016-17 budget represents a 6.6-percent increase over 2014-15 spending levels, with “growth in all of TMA’s priorities,” TMA lobbyist Michelle Romero said.  

Among the recommendations TMA supported:  

  • $53 million for GME expansion grants, roughly $40 million above 2014-15 funding;
  • An additional $50 million for women’s health services;
  • An $80 million increase in mental health and substance abuse funding; and 
  • $20 million dedicated to infectious disease surveillance.   

Senate Finance Committee Chair Sen. Jane Nelson (R-Flower Mound) championed GME expansion from the outset, culminating in her sponsorship of Senate Bill 18. TMA had a big hand in crafting the legislation, which serves as the major vehicle for the $53 million dedicated to expanding first-year residency slots in the 2016-17 biennium, and helping to reach the TMA and Texas Higher Education Coordinating Board’s goal of 1.1 entry-level GME slots per medical school graduate. Programs can use the money to establish new first-year positions, maintain previously unfilled slots, continue positions started with 2014-15 grant funding, or plan brand-new programs.  

Other medical education monies include:   

  • $7 million for primary care physician pipeline programs: $4 million above current funding for the existing family medicine residency program and $3 million to restart the Statewide Primary Care Preceptorship Program;
  • Maintained funding for the State Physician Education Loan Repayment Program;
  • A 22-percent increase in biennial per-resident, or “formula,” funding;
  • A 3-percent increase in medical student formula funding; and
  • Additional money for mental health workforce training programs in underserved areas.   

Physicians also came out winners of a $200 annual tax cut, thanks to House Bill 7 by Rep. Drew Darby (R-Arlington) and Sen. Kevin Eltife (R-Tyler). The bill eliminates the annual occupational tax paid by physicians and a dozen other professions.  

Medicaid Pay Boost Fizzles; Reforms Advance
On the other hand, TMA Advocacy Vice President Darren Whitehurst expressed extreme disappointment with the decision against reinstating the Medicaid-Medicare parity payments for primary care. The pay raise — originally funded by the federal government in 2013 and 2014 — led to a 5-percent bump in physician Medicaid participation “and keeps us from losing doctors in places we can least afford to lose them,” he said.  

The legislature also ignored medicine’s call to fully rescind the 2011 cuts made to coinsurance payments for treating dually eligible Medicare-Medicaid patients. 

TMA won long-sought Medicaid reforms that aim to take away some of the other big reasons doctors don’t participate, besides low pay. One big step in that direction was Senate Bill 207 by Sen. Juan “Chuy” Hinojosa (D-McAllen). The bill outlines clear criteria for Medicaid fraud investigations by the Office of Inspector General (OIG). 

The new law builds on TMA-backed Senate Bill 1803 passed in 2013, which paved the way for due process improvements. SB 207:   

  • Clarifies that “fraud” does not include unintentional technical, clerical, or administrative errors; 
  • Requires probable cause of a credible allegation of fraud for payment holds;
  • Requires OIG to give physicians a detailed summary of its evidence relating to the allegation;
  • Gives OIG 180 days to complete an investigation; and 
  • Gives physicians 10 days to request a confidential, informal settlement meeting.   

Now that Medicaid has moved almost entirely to managed care, other TMA-backed reforms were in Senate Bill 760 by Sen. Charles Schwertner, MD (R-Georgetown), to increase oversight and accountability of Medicaid HMOs’ network adequacy. The bill would suspend enrollment by and payments to health plans if they fail to maintain adequate networks. 

Cutting Red Tape
Other key victories for medicine will go a long way to cut the red tape that takes valuable physician time and money away from patient care.  

DPS backlogs will finally be a thing of the past thanks to Senate Bill 195 by Senator Schwertner. Effective Sept. 1, 2016, the state’s CSR permit program will cease to exist, and physicians will need only their federal Drug Enforcement Administration (DEA) registration to prescribe controlled substances. The backlogs were a nightmare for many physicians who saw their prescribing and hospital privileges — and their patients’ care — temporarily suspended because DPS did not process their permits on time.  

The measure is part of a larger shift under SB 195 to move the state’s electronic prescription drug monitoring database entirely from DPS to the Texas State Board of Pharmacy. TMA, pharmacy groups, and business groups advocated for moving the Prescription Access Texas program to a health-related agency, and the board has until March 1, 2016, to create rules. 

“This move will create significant improvements for doctors,” TMA lobbyist Dan Finch said. “It will make the database a better clinical tool with more timely and accurate data.” Among other enhancements: electronic alerts, out-of-state data, and a broadening of physicians’ authority to delegate who can access the information. 

Physicians also will have fewer hassles identifying health plans sold on the federal exchange. TMA-backed House Bill 1514 by Rep. J.D. Sheffield, DO (R-Gatesville), requires insurers to clearly differentiate whether patients bought coverage through the ACA marketplace by displaying the letters “QHP” on their plan identification cards. The measure gives physicians an opportunity to educate patients about the benefits and limitations of the insurance coverage they purchase. HB 1514 allows physicians to communicate with patients about the importance of paying their premiums and to plan treatment accordingly, particularly long-term treatment, TMA lobbyist Patricia Kolodzey says. 

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 Be Part of HIE Planning for Rural Texas 

Health Information Exchanges (HIEs) are active in several regions of Texas. Public HIEs received federal grant funds several years ago to build infrastructure that would allow physicians and other health professionals to share patient information. HIEs also have the ability to query a patient for health information outside a practice so physicians have relevant patient information at the point of care.  

Healthcare Access San Antonio (HASA) is a nonprofit HIE providing services in and around San Antonio. HASA recently has been commissioned by the Texas Health Services Authority to develop an HIE plan for West Texas and the Panhandle. HASA wants to hear from physicians about their needs and interests to determine how to best serve them.  

Contact HASA Executive Director Gijs van Oort, or call at (210) 918-1357 to provide input in planning for HIE infrastructure in rural Texas.   

Gov. Greg Abbott last month signed House Bill 2641, the TMA-supported bill that gives important new liability protections for physicians using HIEs. The new law states:   

  • “Unless the health care provider acts with malice or gross negligence, a health care provider who provides patient information to a health information exchange is not liable for any damages, penalties, or other relief related to the obtainment, use, or disclosure of that information in violation of federal or state privacy laws by a health information exchange, another health care provider, or any other person.”
  • “Nothing in this section may be construed to create a cause of action or to create a standard of care, obligation, or duty that forms the basis for a cause of action.”    

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 Physicians: Reenroll in Medicaid by March 24, 2016

The Affordable Care Act requires all Medicaid health professionals to reenroll in the program at least once every five years (some professionals must reenroll more frequently). Physicians are next on the list and must reenroll by March 24, 2016. However, if you initially enrolled or reenrolled on or after Jan. 1, 2013, you will be required to reenroll by the date indicated on your enrollment letter.

The Texas Health and Human Services Commission and the Texas Medicaid and Healthcare Partnership (TMHP) have improved the electronic enrollment portal to make it easier for doctors to complete the reenrollment process. (Physicians newly enrolling in Medicaid also can use the portal.) The enhancements apply to applications submitted through the TMHP website on or after April 26, 2015.

The improved electronic application process allows you to:  

  • Upload supporting documentation,
  • Sign the enrollment agreement electronically (e-sign),
  • Receive guidance as you work on the application and see more accurate error messages to avoid mistakes,
  • Receive instruction on how to upload documents and submit the application using an e-signature, and 
  • Expedite processing of your application by reducing the need for printing and mailing documents.   

For physicians currently enrolled in Medicaid, the portal will prepopulate the application with demographic data pulled from the physician’s current account.

To be considered fully reenrolled by the March 24, 2016, deadline, physicians must receive verification from TMHP that the application has been approved before that date. It currently takes about 32 days for applications to be processed. Thus, physicians should reenroll early to avoid gaps in enrollment. The reenrollment requirement also applies to physician assistants and advanced practice registered nurses.

To use the online application, you must have a TMHP user account and a user name (portal user ID). Refer to the TMHP Portal Security Provider Training Manual for instructions on activating a TMHP user account. For more information about Medicaid provider reenrollment, visit the TMHP provider reenrollment page

You’ll find more information on Medicaid reenrollment in the August issue of Texas Medicine

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Federal Judge Sides With Teladoc, Blocks TMB Telemedicine Rule

U.S. District Judge Robert Pitman granted Teladoc’s request for a temporary restraining order (TRO) and preliminary injunction that blocks the Texas Medical Board’s (TMB’s) recently adopted telemedicine rule, which prohibits prescription of dangerous drugs or controlled substances without a “defined physician-patient relationship.” This includes a physical examination via face-to-face visit or in-person evaluation, as TMB defines those terms in the rules. TMB adopted the rule April 10, and it took effect June 3.

In its application for a TRO, Teladoc argued TMB has engaged in anticompetitive actions that would put the company out of business in Texas and lead to “higher prices, reduced choice, reduced access, reduced innovation, and reduced overall supply of physician services.” In response, TMB argued the rule is consistent with “sound medical practice” and is “reasonably necessary for and beneficial to patient welfare.” In the order, Judge Pitman concludes “the balance of respective interests of the parties and the public weigh in favor of granting [Teladoc’s] application for a preliminary injunction.” 

TMA, Southwest Pharmacy Solutions, the American Osteopathic Association, the Texas Osteopathic Medical Association, and the Federation of State Medical Boards filed briefs in opposition to the application for TRO and preliminary injunction. 

The injunction will continue until Teladoc’s federal antitrust lawsuit against TMB is resolved.  

TMA President Tom Garcia, MD, said in a statement that “TMA is sorely disappointed with the court’s decision allowing the writing of prescriptions for dangerous drugs without first establishing a patient-physician relationship. Protecting patient health and safety and improving the quality of patient care are the Texas Medical Board’s responsibilities. TMA supports the challenged rules and believes they fulfill the board’s mission.” 

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Begin Participation in the Medicaid EHR Incentive Program by 2016

Physicians interested in receiving incentives for participation in the Medicaid Electronic Health Record (EHR) incentive program need to begin by adopting, implementing, or upgrading a certified EHR by 2016. It is the last year physicians may begin participation in the program to qualify for an incentive, which pays out until 2021.  

Non-hospital-based eligible professionals with at least 30 percent Medicaid volume could receive up to $63,750 over a six-year period.  

  Year 1 Year 2   Year 3   Year 4   Year 5   Year 6  
 Adopt, implement, or upgrade a certified EHR   $21,250            
Successfully attest to meaningful use program requirements      $8,500 per year for the next five years

Non-hospital-based eligible pediatricians with at least 20 percent Medicaid volume could receive up to $42,500 over a six-year period.

  Year 1 Year 2   Year 3   Year 4   Year 5   Year 6  
 Adopt, implement, or upgrade a certified EHR   $14,167            
Successfully attest to meaningful use program requirements      $5,667 per year for the next five years

To qualify, physicians must meet the volume requirements each year. When calculating the volume, physicians must choose a sample 90-day period from the year prior to participation. Therefore, it is necessary to meet the Medicaid volume requirement in 2015 to participate in 2016. 

In the first year, participants receive the incentive payment for adopting, implementing, or upgrading a certified EHR. In all remaining years, participants must meet meaningful use requirements, just like the Medicare program. It is too late for physicians who already are participating in the Medicare EHR incentive program to switch to the Medicaid program.

Texas Medicaid eligible professionals (EPs) must be enrolled as a performing or billing provider to participate in the EHR incentive program. The enrollment process can be lengthy and may take up to 60 days to complete. If you do not initiate the enrollment process early by completing and submitting the Texas Medicaid Provider Enrollment Application, you may not receive your Medicaid provider credentials in time to meet EHR program deadlines. If you already are enrolled, make sure all credentials are up to date. Read this article from TMHP for additional information on the Medicaid enrollment requirements for the EHR Incentive Program.

For additional assistance with the Texas Medicaid EHR Incentive Program, email, or call the Contact Center at (800) 925-9126 (option 4).

For more information about meaningful use, call the TMA Health Information Technology Department at (800) 880-5720 or email

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 Deadline for Doctors

TMA’s Deadlines for Doctors alerts you and your staff to upcoming state and federal compliance timelines and offers information on key health policy issues that impact your practice.  

ICD-10 Implementation Compliance

First-Year Participants’ Last Day to Begin 90-Day Reporting Period of Meaningful Use for the 2015 Medicare and Medicaid EHR Incentive Programs  

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 Save the Date for TMA Fall Conference

Mark your calendar for the TMA 2015 Fall Conference Sept. 25-26, returning to the Hyatt Regency Lost Pines Resort & Spa in Bastrop. The conference provides an opportunity for physicians and medical students to conduct TMA business, earn continuing medical education, and network with peers.

TMA’s special room rate is $199 for single or double occupancy. Reserve a room by calling (888) 421-1442, and ask for the TMA Fall Conference discount rate. The deadline to book your hotel reservation at the TMA rate is Aug. 28.  

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