Action: Dec. 17, 2012

TMA Action Dec. 17, 2012  
News and Insights from Texas Medical Association


INSIDE: Medicaid Fee Increase Delayed

Dual-Eligibles Cut Partially Restored
State Delays Medicaid Fee Increase
Medicine: Don't Jump Off Fiscal Cliff
Tell Congress to Kill the SGR Zombie
2013 Medicare Enrollment Ends Dec. 31
ICD-10 Nightmare Coming, TMA, AMA Warn
Tied Up in Red Tape?
Aetna Deal Creates Physician Payment Funds

HIT Deadlines Ahead
TMA Attacks TDI Network Adequacy Proposal
Flu Vaccine Finder Adds Physician Option
Legislative News Delivered to Your Inbox
Medicaid, Demographics at Winter Conference
A Healthier Texas and a Happy New Year
This Month in Texas Medicine

Dual-Eligibles Cut Partially Restored

After months of TMA-organized rallies, lobbying, and meetings, the Legislative Budget Board directed the Texas Health and Human Services Commission (HHSC) to restore part of the cut in payments for patients covered by both Medicare and Medicaid.

The tipping point was a meeting State Sen. Juan "Chuy" Hinojosa (D-McAllen) organized at the Capitol last week with Lt. Gov. David Dewhurst and House Speaker Joe Straus. The group included TMA Board of Trustees Vice Chair Carlos Cardenas, MD, of Edinburg, and La Joya family physician Javier Saenz, MD. Although Gov. Rick Perry did not attend the meeting, his support helped move the change over the finish line.

"It's a great first step," said TMA President Michael E. Speer, MD. "Physicians across the state and their patients have been reeling from the impact of these cuts for almost a year. We definitely needed a reprieve. Since January, it's been a true medical emergency. Physicians who care for Texas' most sick and most vulnerable patients have had to borrow money to keep their doors open, lay off staff – some dropped out of the Medicaid program, and some did close their practices."

The 2011 Texas Legislature ordered the cut in dual-eligible payments as a budget-saving move. The way HHSC implemented it covered two pieces of the complex interaction between Medicare and Medicaid payments to physicians. The change effectively:

  1. Stopped Medicaid from covering all of the dual-eligible patients' $140 annual Medicare deductible; and
  2. Prevented Medicaid from paying more than the Medicaid-allowable charge; this stopped Medicaid coverage of the Medicare copay.  

The agreement reached would reinstate coverage of the Medicare deductible in 2013. Exact details of how HHSC would implement that change were still being worked out as this issue of Action was prepared. TMA will keep you informed as we learn more.

South Texas physicians praised Senator Hinojosa, state Rep. Richard Raymond (D-Laredo), state leaders, TMA, and HHSC officials for reaching agreement on the deductibles issue.

"This was indeed a team effort from the rallies we have had here on the border and in countless meetings in Austin," Hidalgo-Starr County Medical Society President Victor Gonzalez, MD, told the Rio Grande Guardian. "Chairman Raymond and Senator Hinojosa and all our elected officials were so helpful and supportive."

Reversing the cut is one of the top priorities identified by TMA's Physicians Medicaid Congress. Dr. Speer said TMA will continue to pressure lawmakers when the legislature convenes in January to restore the remainder of the cut.

"We now urge lawmakers to eliminate the rest of this cut as soon as possible," he said. "While this cut has disproportionately impacted dual-eligible patients with disabilities and seniors, when physicians are forced to close their doors or reduce services, it affects all of our patients."

State Delays Medicaid Fee Increase

The Texas Health and Human Services Commission postponed the Medicaid primary care physician payment increase authorized under the Patient Protection and Affordable Care Act. The law requires states to increase Medicaid payments to Medicare parity for primary care services provided by pediatricians, family physicians, and general internists from Jan. 1, 2013, to Dec. 31, 2014. The federal government will pay the higher costs.

The Centers for Medicare & Medicaid Services (CMS) did not publish final rules implementing the rate increase until Nov. 1, leaving states scrambling to interpret the implementation requirements and to make the necessary system changes, said Helen Kent Davis, director of government affairs for the Texas Medical Association. By late November, it was clear that there were too many outstanding technical issues to be resolved for Texas and other states to start paying the higher rates by Jan. 1, she said.

Regardless when the change does take effect, the state will make retroactive payments for eligible services to Jan. 1 to ensure eligible primary care physicians receive two years of higher payments, Ms. Davis said.

The higher payments will apply to evaluation and management and vaccine administration codes and will benefit physicians who participate in both Medicaid fee-for-service and Medicaid HMO plans, she said. Further, the federal rule specifies that physicians who are pediatric, family medicine, or internal medicine subspecialists also will be eligible for higher payments. Payments for eligible services provided by physician assistants or advanced practice nurses also will increase if patients receive the service under physician supervision. If midlevel providers bill under their own Medicaid numbers, they will be paid 92 percent of the higher rate, the same discount that applies to their services today. Eligible physicians will be required to self-attest that they qualify for the higher payments. Details about the attestation process are not yet available.

In a related issue, TMA President Michael Speer, MD, said in a letter to the Texas congressional delegation that Congress should not reverse CMS plans for the Medicaid physician payment increase to pay for preventing drastic cuts in Medicare payments to physicians. The presidents of the Texas Academy of Family Physicians, the Texas Pediatric Society, and the American College of Physicians-Texas Chapter also signed the letter.

Reversal of the pay hike for Medicaid primary care services is one proposal to pay for stopping the 27-percent cut in Medicare payments scheduled to take effect Jan. 1.

"We cannot turn Medicaid into a more effective delivery system until we shore up Medicaid patients' eroding access to primary care physicians and key specialists," Dr. Speer wrote. "Only 31 percent of Texas physicians now accept all new Medicaid patients, according to a recent TMA survey, and poor payment is the primary culprit. CMS recognized this when it acted to boost Medicaid payments for eligible physician services. Reversing this solution for short-term savings – even if those savings might be used to fix Medicare's glaring payment problems – will ultimately cost lives and more money."

The American Medical Association and national and state medical and specialty societies across the country, including TMA, also wrote congressional leaders to oppose the cut. "The Medicaid payment increase is an important policy that attempts to better align payment rates with cost of care for primary care physicians, thus increasing access to primary care physicians for millions of Medicaid patients," that letter said.

Medicine: Don't Jump Off Fiscal Cliff

Congress should pass "a fiscally responsible, bipartisan agreement" to stop budget cuts that would devastate health programs if the federal government goes over the so-called "fiscal cliff" at the end of the year. That message was delivered in letters to House and Senate leaders of both political parties by TMA, the American Medical Association, and medical societies across the country.

The groups said the across-the-board budget sequestration cuts scheduled to take effect Dec. 31 "would endanger critical programs related to medical research, public health, workforce, food and drug safety, and health care for military families, as well as trigger cuts in Medicare payments to physicians and graduate medical education programs that will endanger patient access to care. While we acknowledge and support the need to reduce our nation's burgeoning budget deficit to a fiscally sound level, we believe that the arbitrary and formulaic sequestration approach is not the appropriate policy to attain our nation's long-term health care goals. Congress should take a more targeted, rational approach that allows careful assessment of how to fulfill its long-term commitment to seniors, uniformed service members and their families, and public health and safety priorities."

The letters called for eliminating the Sustainable Growth Rate formula that threatens a 26.5-percent cut in Medicare payments to physicians on Dec. 31 and preserving existing Medicare payments for graduate medical education and funding for key research, public health, and prevention programs.

TMA and the others urged Congress "to consider the long-term benefits of maintaining funding for programs that are essential to achieving our nation's goal to reform the Medicare payment and delivery system, improve public health and safety, improve access to health care services, and reduce overall health care costs."

The letters stem from a resolution cosponsored by the Texas delegation and approved by the AMA House of Delegates at its meeting in November.

Tell Congress to Kill the SGR Zombie

We need your help to convince Congress to stop the "zombie Medicare financing" it uses to pay physicians. Every year for the past 12, cuts driven by the defective Sustainable Growth Rate (SGR) formula have come back from the dead … but in even worse shape. The SGR crisis is not dead nor does it lie dormant. It's very much alive.

Year after year of payment uncertainty is forcing doctors out of Medicare, making it more difficult for seniors, Texans with disabilities, and military families to get the care they need. In fact, the number of Texas physicians accepting all new Medicare patients dropped from 78 percent in 2000 to only 58 percent in 2012. This statistic is frightening. The crisis can only get worse as millions of baby boomers become of Medicare age.

Please call Washington at 7 am every Tuesday until Congress stops the payment cut and agrees to fix the defective SGR. Join your colleagues to convince Congress to stop this year's 27.5-percent cut. Get commitments from Sens. John Cornyn and Kay Bailey Hutchison and your representative to fix the 12-year-old problem.

For talking points and congressional phone numbers, go to the Medicare Meltdown Action Center.   

TMLT Nest Egg Ad   

2013 Medicare Enrollment Ends Dec. 31

Physicians have until Dec. 31 to enroll in the Medicare program for 2013.

You have three options:

Sign a participation (PAR) agreement and accept Medicare's allowed charges as payment in full for all Medicare covered services for your Medicare patients.  
  1. Elect nonparticipation (non-PAR), which allows you to make assignment decisions on a case-by-case basis and to bill patients up to the Medicare limiting charge for unassigned claims.  
  2. Opt out and become a private contracting physician, agreeing to bill patients directly and forego any payments from Medicare to your patients or yourself. To become a private contractor, PAR physicians must give 30 days' notice before the first day of the quarter the contract takes effect. For non-PAR physicians, the opt-out effective date is the date the affidavit is signed, provided it is filed within 10 days after the physician signs his or her first private contract with a Medicare beneficiary.   

Novitas Solutions, which replaced TrailBlazer Health Enterprises as the Medicare contractor for Texas on Nov. 19, has several resources on its website. They include an overview of Medicare assignment, participation, and the opt-out process. A separate page on the Novitas website offers more detailed information on the opt-out process. The page also includes a sample affidavit a physician must file if he or she decides to opt out.  

ICD-10 Nightmare Coming, TMA, AMA Warn

Forcing physicians to begin using the ICD-10 coding system in 2014 will create a financial and administrative nightmare for them, warn TMA, the American Medical Association, and other state medical societies in a letter to the Centers for Medicare & Medicaid Services (CMS). They called on CMS to stop the switch and work with all interested parties to find a better replacement for the ICD-9 coding system.

"The implementation of ICD-10 will create significant burdens on the practice of medicine with no direct benefit to individual patient care, and will compete with other costly transitions associated with quality and health IT reporting programs," the letter says. It adds that physicians already face a 27-percent cut in Medicare payments on Jan. 1 caused by the Sustainable Growth Rate formula, plus another 2-percent fee cut if the federal government goes over the "fiscal cliff" at the end of the year.

"Stopping the implementation of ICD-10 is a critical, necessary step for removing regulatory burdens on physicians and ensuring that small physician practices are able to keep their doors open," the letter says.

The letter says switching to ICD-10 will cost a medical practice anywhere from $83,290 to $2.7 million, depending on size of the practice, and will disrupt physicians' efforts to implement health information technology and participate in new delivery and payment reform models.

If CMS doesn't relent or if Congress doesn't force it to, ICD-10 will become a reality, thus TMA advises physicians to prepare for the transition. "Waiting until the last minute or expecting CMS to postpone the implementation date sets a medical office up for loss of productivity and decreased revenue," Edinburg pediatrician Martin Garza, MD, a member of the TMA Council on Practice Management Services, told Texas Medicine in a story on ICD-10 preparations to be published in January.

TMA has a variety of ways to help physicians get ready. For example, TMA collaborated with Louisiana-based Complete Practice Resources (CPR) to develop web-based tools that help physicians successfully transition to ICD-10 and help ensure they continue receiving payments after Oct. 1, 2014.

One of them is the Simple Solutions ICD-10 Transition Software. The software can generate a practice's top 50 codes in a matter of minutes. It can also create coding flash cards of most commonly used diagnoses that physicians can share with their staff members. It allows physicians and office staff members to search ICD-9 and ICD-10 by code, description, and key word; create and save a list of commonly used codes; and develop and print quick-reference conversion lists.

TMA is working with CPR to finalize the Simple Solutions ICD-10 Tool Kit, which includes the software. Contact the TMA Knowledge Center at (800) 880-7955 to inquire about product availability.

In addition, TMA Practice Consulting offers a variety of services to help ensure your reimbursement doesn't suffer during the ICD-9 to ICD-10 transition. Contact TMA Practice Consulting by telephone at (800) 523-8776 or by email.

Log on to the TMA Practice Consulting website for a rundown of all the services it offers, including the coding hotline and Hassle Factor Log program.

Physicians should also check the CMS ICD-10 website for the latest information.

Tied Up in Red Tape?

TMA wants to hear from you as part of its red-tape reduction effort in the 2013 session of the Texas Legislature. What administrative hassles do you face? Where does the red tape need to be cut and how?

Log on to TMA's Red Tape Hassle Log to share your complaints and suggested solutions. Or light up the phones of the TMA Knowledge Center at (800) 880-7955.

As the December Texas Medicine reports, TMA plans to file an omnibus red-tape reduction bill when the legislature convenes in January. Key features of the bill will address last year's backlog in issuing controlled substance permits; ensure that the new Department of Public Safety online prescription drug-monitoring database remains secure and user-friendly for physicians; and push lawmakers for other in-office conveniences that mean less time spent on needless paperwork and more time dedicated to patients.

Aetna Deal Creates Physician Payment Funds

Aetna has agreed to pay physicians and patients $120 million because it used databases that deflated rates for out-of-network services.

The decisions stems from settlement of a 2009 lawsuit against Aetna by TMA, the American Medical Association, and state medical societies in California, Connecticut, Florida, Georgia, New Jersey, New York, North Carolina, Tennessee, and Washington. The suit alleged Aetna used databases created by Ingenix, Inc., a subsidiary of UnitedHealthcare, to set usual, customary, and reasonable (UCR) rates for out-of-network services. It said Ingenix databases were inherently flawed and unable to establish proper UCR rates.

Physicians will be notified once the judge in the case approves the settlement, and they will have 90 days to file a claim, said Edith Kallas, an attorney for the plaintiffs. The notice will include information about how to file a claim.

Aetna, United, and other insurers agreed to stop using the Ingenix database in settlements with the New York State Attorney General in 2009. That settlement created FAIR Health to take over and improve the database and establish transparent, current, and reliable health care charge information.



HIT Deadlines Ahead

With multiple health information technology (HIT) incentive programs at play right now, physicians should consider deadlines as they make year-end plans.

Feb. 28: Medicare electronic health record (EHR) incentive program attestation deadline
If you are attesting for the Medicare meaningful use incentive program, you have until Feb. 28 to complete your attestation for payment year 2012. If this is your first year participating in the program, you will report on 90 days of meaningful use. If this is your second payment year, you are reporting on a full calendar year of meaningful use. This includes patient encounters up to Dec. 31, 2012.

Feb. 28: E-prescribing incentive program
If you are submitting claims for the 1 percent e-prescribing bonus for payment year 2012, you have until Feb. 28 to submit the claims with G-code G8553 for Medicare patients whose prescriptions were successfully sent to the pharmacy electronically. As a reminder, physicians must submit prescriptions for 25 different Medicare patients seen in 2012 and report the G-code on the claim form to be eligible.

March 16: Medicaid EHR incentive program attestation deadline
Physicians must complete their meaningful use attestation or certified EHR attestation and be in “payment pending” status by March 16 to receive 2012 payment year incentives.

Do not wait until the last possible day to submit information; last year, there were widespread outages due to a system overload. TMA recommends you have everything complete by Jan. 31, 2013, to avoid last-minute problems that could negate the incentives for which you have worked so hard.

TMA recognizes the complexities of compliance with the HIT incentive programs and encourages you to contact your local regional extension center (REC) established by the Office of the National Coordinator for Health Information Technology to specifically help with program compliance. The RECs can help all physicians but may be able to discount services for primary care physicians. Details about the REC program are available through the Texas Regional Extension Center Resource Center on the TMA website.

For more information, call the TMA Health Information Technology Department at (800) 880-5720 or email HIT. And to stay up-to-date with all the looming regulatory deadlines, check-in often at TMA's Calendar of Doom.

TMA Attacks TDI Network Adequacy Proposal

The Texas Department of Insurance's (TDI's) proposed rules governing the adequacy of physician networks in insurance plans are bizarre, misguided, "extremely poor public policy," unacceptable, inappropriate, feeble, confounding, insurer-friendly, and unsupportable, TMA President Michael Speer, MD, wrote to TDI earlier this month.

"If the Department's current path is not abandoned, it will ultimately result in irreparable harm to Texas' consumers as, inter alia, the value of the products they have purchased will be reduced; their out-of-pocket expenses will be increased; and unjust and deceptive policies will (by the Department's own admission) be allowed in the market for purchase by unsuspecting consumers," Dr. Speer wrote.

TMA, TDI, and the health plans have been involved in lengthy negotiations over the rules since TMA pushed passage of network adequacy laws in the 2007 and 2009 sessions of the Texas Legislature. Shortly before they were to take effect, TDI Commissioner Eleanor Kitzman late last year suspended a solid package of rules TMA helped to put together.

Flu Vaccine Finder Adds Physician Option

Thanks to prodding by TMA and three specialty societies, creators of the HealthMap Vaccine Finder website added wording reminding patients they can get flu shots from their physician. The website tells patients where they can get influenza vaccinations in their neighborhoods.

Children's Hospital at Harvard and the U.S. Department of Health and Human Services (HHS) added "You can always contact your physician's office to get your flu shot" to the right side of the page, directly beneath where patients select their flu vaccine options. They did so after TMA, the Texas Pediatric Society, the Texas Academy of Family Physicians, and the American College of Physicians-Texas Chapter wrote HHS in September because the website did not acknowledge the medical home as the first place to seek flu shots. It primarily listed freestanding and grocery store pharmacies that provide the influenza vaccine. Lewis Foxhall, MD, vice president of health policy at The University of Texas MD Anderson Cancer Center and a member of the TMA Board of Trustees, alerted TMA to the problem.  

HHS officials acknowledged that TMA and the specialty societies were correct. "Your point is well taken, and we are already exploring options to resolve the oversight," an HHS official wrote.

Here are instructions to make sure your practice shows up on the website:

  • To upload your office's information, you'll first need to create an account.
  • You will receive a password via email once your account is approved, usually within 24 hours.
  • You can then log in.
  • Once logged in, click on the Add Provider tab. If you are adding one or a few locations, just scroll down to the Individual Provider Entry Form and fill out the relevant fields. Be sure to press "Submit" at the bottom of the page.
  • If you need to add multiple locations, use the "Upload a Spreadsheet" tool at the top of the Add Provider tab. Download the spreadsheet template, fill in the relevant fields, and upload as a .csv file. Please see the formatting tips under the Help tab to ensure you format your spreadsheet correctly.  

Further assistance is on the Help tab, or email

Legislative News Delivered to Your Inbox

The next session of the Texas Legislature promises to be action-packed, and you don't want to miss the action under the Capitol dome. You won't miss a thing if you sign up for the TMA Legislative News Hotline.

The electronic newsletter reports the legislature's latest actions on bills affecting you, your practice, and your patients. It's delivered daily before noon starting Jan. 2. A weekly recap, delivered each Friday, also is available.  

This year, the hotline also will bring you weekly video updates from TMA lobbyists, health care experts, and even state legislators. Don't miss out. Subscribe today.   

What Can Practice Production Numbers Tell You?

Consider these factors if your production isn't consistent.  

A practice management tip from
TMA Practice Consulting


Medicaid, Demographics at Winter Conference

Medicaid's future and the changing face of Texas highlight the agenda for the 2013 TMA Winter Conference, Feb. 1-2, at the AT&T Conference Center in Austin.

Health and Human Services Commissioner Kyle Janek, MD, and a panel of physicians and legislators will discuss the Medicaid program in Texas and the progress TMA's Physicians Medicaid Congress is making in suggesting ways to improve the program. Former state demographer Steve Murdock, PhD, will make a presentation on changes in the state's demographics and what it means for medicine.

Book your hotel reservation by Jan. 11 to get the discounted rate.

Watch your email and the Winter Conference webpage for more information.

A Healthier Texas and a Happy New Year

Time is running out to make a year-end, tax-deductible donation and ensure that more Texans learn the value of prevention and how to stay healthy in 2013. It takes nearly $400,000 for TMA's award-winning programs to reach Texans in need. You can help create a "Healthy Now" and "Healthy Future" with your donation to TMA Foundation today!

It’s easy to donate online, so don't miss your chance – make your gift today. Your gift in 2012 will ensure thousands more Texans are reached in 2013 and beyond.

This Month in Texas Medicine

The December issue of Texas Medicine tells you why TMA is concerned about new state antifraud rules that presume a physician is guilty. You'll also learn about TMA's plan to push an anti-red tape bill in the next legislative session and what the government expects of you in its electronic health record rules. Finally, you'll find out what the "Choosing Wisely" program is all about.

Check out our digital edition.

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.   

This Just In ...

Want the latest and hottest news from TMA in a hurry? Then log on to Blogged Arteries.

TMA Education Center  

The TMA Education Center offers convenient, one-stop access to the continuing medical education Texas physicians need. TMA's practice management, cancer, and physician health courses are now easier than ever to find online.

Physician Health and Rehabilitation, Ext. 1342

Interventions for Health: PHR Training Session and 20th Annual Retreat
2-22/23 Horseshoe Bay

Healthy Physicians: Healthy Patients
4/6         Lubbock
4/27       Fort Worth

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