Action: Feb. 1, 2013

TMA Action Feb. 1, 2013  
News and Insights from Texas Medical Association  


INSIDE: Good News in Dual-Eligible Crisis  

State Now Paying Dual-Eligibles’ Medicare Deductible
Time to Decide About Medicare
CMS Cuts Fees for EMG/NC Studies
Texas Clinics Repay Medicare for Improper Claims
2013 E-Rx Penalty and Incentive Guidelines
G8447 Is Retired

Health Care in President's Gun Control Bull's-Eye
TMLT Covers Employment Disputes
Your Chance to Protect Little Heads
Take HEED of Costs
TMA Members Are Winners
This Month in Texas Medicine

State Now Paying Dual-Eligibles’ Medicare Deductible

The Texas Health and Human Services Commission (HHSC) restored the Medicare Part B deductible payment on Jan. 25 for patients eligible for both Medicare and Medicaid, also known as "dual eligibles."

From Jan. 25 on, the Texas Medicaid & Healthcare Partnership (TMHP), the Medicaid fee-for-service claims payer, is paying the full deductible amount owed. TMHP will automatically process claims filed before Jan. 25 back to Jan. 1.

TMHP has not announced when claims reprocessing will begin, but will publish the schedule on its website when known. If the patient is enrolled in a Medicare Advantage plan contracted with the state to pay dual-eligible patients' cost-sharing, the plan will restore payment of the deductible.

In 2011, the legislature ordered HHSC to cut dual-eligible payments to save money. The two-part reduction eliminated Medicaid's full payment of the annual deductible, which totals $147 in 2013, and stopped payment of dual-eligible patients' coinsurance if the Medicare payment for a service exceeded the Medicaid allowable, which is almost always the case for physician services. Together, the new policy resulted in more than a 20-percent payment reduction for physicians who care for those patients.

The restoration of the deductible comes none too soon. For the past year, the cut has wreaked financial havoc on physicians who care for this population, forcing a growing number of them to lay off staff, curtail services, or take out personal loans rather than stop seeing those patients. Unfortunately, many have been forced to limit the number of dual-eligible patients they will accept or even drop out of Medicaid. Physicians hardest hit were those who see large percentages of dual-eligible patients, many of whom are the poorest and sickest in Texas.

The Texas Medical Association organized rallies and met with state leaders asking for their help to restore the payments. A top priority for TMA during the 2013 legislative session is to restore the coinsurance payments.

Time to Decide About Medicare

Time is running out to decide if you will participate in Medicare this year. Feb.15 is the deadline to make a decision. TMA will help you decide with a new webinar discussing your three options.

Novitas Solutions, the Texas Medicare administrator, posted the 2013 Texas fee schedule on its website.

The Centers for Medicare & Medicaid Services extended the deadline in January after Congress passed and President Obama signed last-minute legislation to avert the so-called "fiscal cliff." Part of the deal stopped the scheduled 28.5-percent cut in Medicare payments to physicians, freezing fees through Dec. 31, 2013.

If you currently are participating or not participating and want to stay that way, you do not have to do anything. Otherwise, you have three options in deciding whether to participate in 2013:

  1. Sign a participation (PAR) agreement and accept Medicare's allowed charge as payment in full for all Medicare covered services for your Medicare patients.
  2. Elect nonparticipation (non-PAR), which permits you to make assignment decisions on a case-by-case basis and to bill patients up to the Medicare limiting charge for unassigned claims.
  3. Opt out and become a private contracting physician, agreeing to bill patients directly and forego any payments from Medicare. 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 you sign the affidavit, provided you file it within 10 days after you sign your first private contract with a Medicare beneficiary.

Novitas 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 you must file if you decide to opt out.

CMS Cuts Fees for EMG/NC Studies

Neurologists and physiatrists throughout the country awoke Jan. 1 to a dramatic cut by the Centers for Medicare & Medicaid Services (CMS) in valuation of electromyogram/nerve conduction (EMG/NC) studies. Physicians who perform these studies are concerned that patients, regardless of coverage, may lose access to this critical diagnostic test.

The Texas Neurological Society (TNS) and the American Academy of Neurology (AAN) need personal stories from physicians and patients demonstrating the effect of this action on patient's access to care.

"Currently, there is an advocacy effort under way that requires that you share your story," said TNS President Sara Austin, MD, of Austin. "The AAN has informed its members that CMS has asked for information on patient access-to-care problems caused by the cuts in the 2013 Medicare fee schedule. We ask that you help in this effort and share your feedback with AAN through Mike Amery at"

Advocacy efforts under way in Washington cannot succeed without direct input and specific data about your personal experiences.

For the most up-to-date information on how AAN advocacy is progressing on this issue, visit the AAN website

TMLT Nest Egg Ad  

Texas Clinics Repay Medicare for Improper Claims

Several Texas dialysis clinics in El Paso and the Dallas-Fort Worth area have had to repay Medicare for treating people in the country illegally.

TMA's Payment Advocacy Department Director Genevieve Davis says the practices had to write off the money recouped because they either could not find the patient or the patient is deceased. Ms. Davis added there is no way for a practice to verify a patient's legal status. If the patient has a Medicare card, the practice staff assumes the Centers for Medicare & Medicaid Services verified he or she is in the country legally.

The U.S. Department of Health and Human Services Office of Inspector General (OIG) said CMS did not determine the patients' status until after it paid the claims. It said CMS needs a better system to verify the legal status of patients. OIG defines a nonlawful resident as someone "who remains in the United States longer than the time authorized by U.S immigration agencies."

Nationally, the OIG reports Medicare improperly paid $91.6 million for treating illegal residents between 2009 and 2011.The agency pointed out that federal law allows Medicare payments for noncitizens legally present in the United States.

2013 E-Rx Penalty and Incentive Guidelines

You have until June 30 to avoid a 2-percent penalty on all 2014 Medicare Part B claims. If you do not already e-prescribe in your office, now is the time to begin. If you do not already use an electronic health record (EHR) system with e-prescribing capabilities, you can install a stand-alone e-prescribing system and still meet the approaching deadline.

You must report e-prescribing via claims using G-code G8553 on at least 10 unique Medicare encounters by June 30 to prevent the penalty. Three prescriptions for one patient encounter will count as only one e-prescribing incident.

Report at least 25 times by Dec. 31 to qualify for a 0.5-percent bonus of Medicare Part B claims (and prevent the penalty in 2015). Follow the instructions in TMA's 2013 e-prescribing informational paper. Email or call the TMA HIT helpline for more information at (800) 880-5720.

If you need help with e-prescribing, turn to the Texas regional extension centers (RECs). RECs provide support to help with e-prescribing, EHR selection, workflow analysis, staff training, EHR incentives, and much more. Visit TMA's Texas REC Resource Center for more information.

The Centers for Medicare & Medicaid Services (CMS) began the e-prescribing incentive in 2009 to encourage e-prescribing to improve the efficiency and safety of health care. E-prescribing is a way to prevent medication errors that arise due to difficulties in reading or understanding handwritten prescriptions.

If you plan to apply for the Medicare EHR incentive in 2013, note that you can't receive the e-prescribing incentive in the same payment year. Physicians applying for the Medicaid EHR incentive are still eligible for e-prescribing incentive payments.

2012 Penalty
If you did not e-prescribe and report the G-code at least 10 times by June 30, 2012, or did not apply for and receive an exemption, you are penalized 1.5-percent of your Medicare Part B claims. Physicians who act this year will be made whole in 2014. There is no formal appeal or informal review process for the 2013 penalties. A new exemption is available for physicians who use a certified EHR and either register or attest for the meaningful use EHR incentive program by June 30.

You may submit all inquiries to the QualityNet Help Desk for CMS examination. You may contact the help desk via telephone at (866) 288-8912 [TTY (877) 715-6222] from 7 am to 7 pm CST Monday through Friday, or via email.

G8447 Is Retired

G8447 was a Physician Quality Reporting System (PQRS) code used to indicate the patient encounter was documented using a certified electronic health record (EHR). As of Jan. 1, this is a deleted code, and that particular PQRS measure is now retired.

A few practices have contacted TMA thinking that reporting this G-code qualified them for the EHR incentive program and entitled them to a bonus. That is not the case. The EHR incentive program requires attestation to meaningful use measures. Please see instructions for the Medicare and Medicaid programs. TMA also has an EHR Incentive Program Resource Center that compiles resources to help physicians.

TMA recognizes the complexities of compliance with the EHR incentive program and recommends physicians contact their local regional extension center (REC), established by the Office of the National Coordinator to 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 on the TMA website.

Questions may be directed to the TMA Health Information Technology Department by telephone at (800) 880-5720 or by email.



Health Care in President's Gun Control Bull's-Eye

While his proposal for a new law to ban the sale of assault weapons grabbed the early headlines, a number of pieces of President Obama's plan to reduce gun violence involve physicians and the health care system.

Already drawing controversy, for example, is the president's announcement that he will "clarify that the Affordable Care Act [ACA] does not prohibit doctors asking their patients about guns in their homes."

In an article entitled "Obama: Doctors Should Ask About Guns in Homes," the conservative NewsMax publication says that provision "sounds like George Orwell's 1984." From the other side, The Atlantic reported that "the order actually just preserves a legal expectation for doctors to report on their patients that has existed for 37 years."

All in all, a review of the president's 23 executive actions and nine legislative proposals reveals much that will – or could – impact physicians and patients and the health care system. (See below for the official White House press briefing on the pieces of the plan.)

One piece is already a formal executive order signed by the president: "The Secretary of Health and Human Services (Secretary), through the Director of the Centers for Disease Control and Prevention and other scientific agencies within the Department of Health and Human Services, shall conduct or sponsor research into the causes of gun violence and the ways to prevent it. The Secretary shall begin by identifying the most pressing research questions with the greatest potential public health impact, and by assessing existing public health interventions being implemented across the Nation to prevent gun violence."

"And while year after year, those who oppose even modest gun safety measures have threatened to defund scientific or medical research into the causes of gun violence," the president said at his news conference, "I will direct the Centers for Disease Control to go ahead and study the best ways to reduce it – and Congress should fund research into the effects that violent video games have on young minds. We don't benefit from ignorance. We don't benefit from not knowing the science of this epidemic of violence."

The other six executive actions related to health care are:

  • Address unnecessary legal barriers, particularly relating to HIPAA, that may prevent states from making information available to the background check system.
  • Release a letter to health care professionals clarifying that no federal law prohibits them from reporting threats of violence to law enforcement authorities.
  • Release a letter to state health officials clarifying the scope of mental health services that Medicaid plans must cover.
  • Finalize regulations clarifying essential health benefits and parity requirements within the ACA exchanges.
  • Commit to finalizing mental health parity regulations.
  • Launch a national dialogue on mental health led by Health and Human Services Secretary Kathleen Sebelius and Education Secretary Arne Duncan.

And the two pertinent pieces of President Obama's legislative agenda on gun violence are:

  • Help ensure that young people get the mental health treatment they need.
  • Ensure health insurance plans cover mental health benefits.

The first item, according to the White House press briefing, is aimed at training teachers, school counselors, social workers, and others who routinely work with students and young adults.

TMLT Covers Employment Disputes

The Texas Medical Liability Trust (TMLT) began offering free added employment practices liability insurance (EPLI) to all TMLT policyholders on Feb. 1.

EPLI covers lawsuits caused by several employment-related events, including harassment, discrimination, Family and Medical Leave Act violations, hostile work environment, and wrongful termination. Limits of liability are $50,000 per claim (including both defense costs and indemnity payments) with a $5,000 deductible. The yearly aggregate limit is also $50,000. Higher limits are available for purchase.

"Today, employment practices-related claims are a credible threat to physicians' practices. EPLI coverage is crucial to insure against that threat,” said TMLT President and Chief Executive Officer Charles R. Ott Jr. "No other Texas-based medical professional liability carrier offers this benefit to all policyholders at no extra premium."

If you are interested in becoming a TMLT policyholder, apply on the TMLT website or call the sales department at (800) 580-8658, ext. 8603. If TMLT already covers you and you have questions, call (800)-580-8658 and ask for your underwriter.

The largest medical liability insurance provider in Texas, TMLT serves more than 16,000 TMA member physicians. Rated "A (Excellent)" by A.M. Best Company, TMLT was created and is endorsed by TMA.

Your Chance to Protect Little Heads

Three great times to host a TMA Hard Hats for Little Heads helmet giveaway are approaching. March is Brain Injury Awareness Month, April is Texas Child Safety Month, and May is Bike Month.

TMA encourages physicians, county medical societies, medical students, and TMA Alliance members to give free helmets to children in your community. TMA provides free helmets with your purchase of helmets. Buy 50 helmets at our reduced cost of $7.35 each, and we'll give you 50 helmets free.

Check out these ideas for events, and start planning your event now. To learn more, contact Tammy Wishard, TMA outreach coordinator, at (800) 880-1300, ext. 1470, or (512) 370-1470.

Hard Hats for Little Heads is made possible through a grant from TMA Foundation thanks to top donors – Blue Cross and Blue Shield of Texas, Prudential, and two anonymous foundations – and gifts from physicians and their families.  

What Can Practice Production Numbers Tell You?

Consider these factors if your production isn't consistent.  

A practice management tip from
TMA Practice Consulting


Take HEED of Costs

The TMA Knowledge Center is evaluating a database called Health Economic Evaluations Database (HEED). Produced by Wiley, it provides comparative analyses of costs and consequences about medicines and other health care interventions for informed decision making.

Users will find comprehensive coverage of economic evaluations, including:

  • More than 47,500 selected records and bibliographies from databases such as MEDLINE® and Embase;  
  • Data from more than 5,000 journals, including Health Economics;  
  • Entries (in bibliographic detail) from the Wellcome and Battelle databases of economic evaluation literature;
  • More than 7,200 abstracts from evaluations appearing in peer-reviewed journals, and
  • Approximately 250 new references added to the database with each monthly update.

This database is available for demonstration on the TMA Knowledge Center Online Databases page. Please take advantage of this limited-time free trial, and email your feedback to Barbara Tims. If you find the database useful, TMA may add it to its free member benefit databases.

If you have trouble accessing the TMA databases, contact the TMA Knowledge Center by telephone at (800) 880-7955 or by email.

TMA Members Are Winners

Leslie Kennedy, MD, Corsicana; Karen Benz, MD, Fort Worth; and Susan Van De Water, MD, Midland, are the winners in TMA's Personalize Your Homepage drawing. They each won a copy of TMA's Policies & Procedures – A Guide for Medical Practices.

TMA had such a big response, the association extended the drawing. Personalize your TMA homepage by March 31 and you will be eligible to win one of three copies of TMA's publication Fraud and Abuse by Amanda Hill.

It's easy:

  • Check the "Keep Me Logged In" box next time you log in with your TMA username and password. Did you forget your TMA username or password? The TMA Knowledge Center has the answer. Call (800) 880-7955 or email the TMA Knowledge Center.

Click on Update Your Profile to tell us your specific interests.

After that, anytime you visit us, you'll be logged in automatically to your personalized TMA homepage. Why not make it your browser homepage, too, so you can follow the topics important to you whenever you go online?

This Month in Texas Medicine

The February issue of Texas Medicine advises physicians on things they need to consider when deciding whether to join a practice or go solo. It also explains how TMA Practice Consulting can help with practice set-up, outlines the Public Health Coalition's priorities for the 2013 legislative session, and delves into changes in the workers' compensation drug formulary.  

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

About Action 

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