Action: March 18, 2013

TMA Action March 18, 2013                         News and Insights from Texas Medical Association          

  INSIDE: Medicare Fee Cut Coming in April     

Medicare Sequester Fee Cut Begins April 1
Non-Enrollees' Medicare Claims Denials Start May 1
Medicaid Fee Hike Requires Eligibility Confirmation
EHR Incentive Payments Are Taxable Income
Poster Session on Quality at TexMed
LSMS Surveys EHR Adoption
Compliance Must Be Part of Your Practice
TMA, CMS, Justice Fight ID Theft
This Month in Texas Medicine
Medicaid Expansion, Scope Win Steal Legislative Limelight               


Medicare Sequester Fee Cut Begins April 1

Medicare will cut physician payments for fee-for-service claims with dates of service on or after April 1 by 2 percent, thanks to the failure of Congress and President Obama to avoid across-the-board federal spending reductions required by the federal budget sequestration that took effect March 1.

The Centers for Medicare & Medicaid Services said it will apply the reduction to claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.

The Medscape Today website reported Medicare also will cut incentive payments for meaningful use of electronic health records by 2 percent. Medicaid incentives are not affected because they are not subject to sequestration, it said.

Medicare funding for graduate medical education also will drop 2 percent, while total federal health care spending will decrease by about 5 percent. Among the areas facing cuts are research and public health programs of the National Institutes of Health, the Centers for Disease Control and Prevention, and the Substance Abuse and Mental Health Services Administration.

The Texas Department of State Health Services is asking physicians to complete a survey on the impact of the cuts on mental health and substance abuse programs by 5 pm CDT March 22.

The Texas Medical Association and the American Medical Association are still lobbying Congress to repeal the Sustainable Growth Rate (SGR) formula that threatens to cut Medicare payments to physicians by 27 percent on Jan. 1, 2014. TMA, AMA, and more than 100 other state medical associations and specialty societies said in letter to Congress last fall that sequestration and SGR cuts "would not only impede improvements to our health care system, it could lead to serious access-to-care issues for Medicare patients as well as employment reductions in medical practices."

"In Texas, the jobs of 258,529 employees of medical practices, as well as access to care for 3,187,332 Medicare patients and 869,573 TRICARE patients are at risk due to these cuts," warns an AMA state-by-state analysis of the impact of sequestration and SGR cuts.

Non-Enrollees' Medicare Claims Denials Start May 1

Starting May 1, Medicare will deny claims for services ordered or referred by a physician who is not enrolled in Medicare. Physicians who receive claim denials will need to contact the ordering or referring physician to verify that he or she has enrolled in Medicare to prevent future denials.

The Centers for Medicare & Medicaid Services (CMS) says physicians who order such services and are not enrolled should do so immediately, or the applications may not be processed before May 1. The national CMS ordering/referring file can be found on the CMS website.

CMS will conduct a National Provider Call-In on the change from 2 to 3 pm CDT on Wednesday, March 20. Registration closes at 11 am CDT that day.

Physicians who have opted out of Medicare can order items or services for Medicare beneficiaries by submitting an opt-out affidavit to Novitas Solutions, the Texas Medicare claims administrator. The opt-out information must be current: An affidavit must be completed every two years, and the physician's National Provider Identifier (NPI) is required on the affidavit.

For more information, read the MLN Matters article.

If you are reconsidering your Medicare participation status, TMA offers a webinar on physicians' Medicare participation options.

Medicaid Fee Hike Requires Eligibility Confirmation

Primary care physicians who treat Medicaid patients will receive fee increases for 2013 and 2014 under the Patient Protection and Affordable Care Act, but only if they sign an attestation form confirming they're eligible for the raise, state officials say.

Although the state received the final federal rules too late to begin the higher payments on Jan. 1, the Texas Medicaid & Healthcare Partnership (TMHP) will make retroactive payments to that date. The state anticipates beginning payments in midsummer.

Under federal rules, physicians will qualify for the rate increase if:

  • They practice family medicine, general internal medicine, pediatrics, or a subspecialty within those designations recognized by the American Board of Medical Specialties, the American Osteopathic Association, or the American Board of Physician Specialties, and
  • They are board certified in an eligible specialty or subspecialty designation and practice in primary care, or more than 60 percent of the services they provide are primary care services eligible for the rate increase. Specifically, the increase will apply to evaluation & management codes 99201 through 99499 and vaccine administration codes 90460, 90461, 90471, 90472, 90473, and 90474. Preventive care codes for new and established patients also will be included in the increase even though Medicare does not cover them.

New physicians with no history of Medicaid billings can attest that 60 percent of their Medicaid billing will be for primary care services, the Texas Health and Human Services Commission (HHSC) said.

HHSC has not yet set a deadline for filing the attestation form but says it will continue to keep physicians informed of the timeline. However, TMA encourages physicians to complete and return the form as soon as possible.

The higher payments will benefit physicians who participate in both Medicaid fee-for-service and Medicaid HMO plans, said Helen Kent Davis, director of government affairs for TMA. Further, the rate increase will significantly help those physicians hurt by the cut in payment for the Medicare Part B coinsurance enacted in 2012. Currently, for those patients, Texas will not pay the 20-percent coinsurance if what Medicare pays is more than the Medicaid allowable for the same services. However, once the rate increase takes effect, eligible physicians will be paid the full coinsurance because the Medicare and Medicaid allowable for the service will be the same.

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.

For more information, call the TMHP Contact Center at (800) 925-9126.      


EHR Incentive Payments Are Taxable Income

Incentives paid under the Medicare electronic health record (EHR) incentive program are taxable, the Internal Revenue Service ruled in February.

Physicians should have received an IRS Form 1099 from the Centers for Medicare & Medicaid Services for the incentive payments. The forms had to be postmarked by Jan. 31 and were mailed to  addresses on file with Novitas Solutions, the Texas Medicare claims processor.  

If you did not receive your Form 1099, you may request a duplicate copy by calling (888) 734-5433, which will take you through a series of prompts (1-1-1-1-2). You will be asked for your National Provider Identifier.  

Physicians in the Medicaid EHR incentive program should have received a Form 1099 from the Texas Medicaid & Healthcare Partnership. You can get a duplicate copy by calling (800) 925-9126. 

The Internal Revenue Service issued guidance on the EHR incentive payments that may help in tax preparation, especially if payments were assigned to your group or hospital.  

TMA recognizes the complexities of compliance with the federal EHR incentive program and encourages physicians to contact their local regional extension center (REC), which the government established to help with program compliance. The RECs can help all physicians, but they may be able to discount services for primary care physicians. Details about the REC program are available on TMA's Regional Extension Center Resource Center.

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

Poster Session on Quality at TexMed

TMA's first Quality Poster Session will take place at TexMed 2013 in San Antonio. Physicians will have the chance to share their successes and breakthroughs in improving patient care with their peers from around the state.

This will be a great opportunity for physicians to not only report on their quality improvement methods and best practices, but to also gain inspiration from their colleagues' approaches to providing quality patient care and to identify new quality improvement techniques to implement in their own practices.

Have a quality improvement success you want to present? It's not too late to submit your poster. Creatively and visually depict something special that you are doing in your practice that demonstrates one or more of the six aspects of quality care as defined by the Institute of Medicine:

  • Safe: avoids injuries to patients from care that is intended to help them.
  • Timely: reduces waits and delays for both those who receive care and those who give care.
  • Effective: based on scientific knowledge, extended to all likely to benefit while avoiding underuse and overuse.
  • Equitable: provides consistent quality, without regard to personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.
  • Efficient: avoids waste, including waste of equipment, supplies, ideas, and energy.
  • Patient-centered: respects and responds to individual patient preferences, needs, and values, ensuring that patient values guide all clinical decisions.    

TMA and TMF Health Quality Institute will host an official presentation from 8 to 9 am on Saturday, May 18, at TexMed, during which the poster authors will have the opportunity to talk about their creations. The posters will then be on display for viewing throughout the rest of the day.

Share your successes, improve the quality of health care in Texas, and support your colleagues. Visit the TexMed Quality Poster Session page for more information or to download an application packet.       

 TMLT Nest Egg Ad     

LSMS Surveys EHR Adoption

The Louisiana State Medical Society (LSMS) is asking Texas physicians to take part in a nationwide survey on physicians' adoption of electronic health records (EHRs). The survey expands on a statewide study the medical society conducted in 2011.

The society received a Physicians Foundation grant to study EHR use among physicians.

The report on the survey will address:

  • Factors that discriminate between nonadopters and adopters;
  • The presence of specific regional drivers (or inhibitors) of EHR adoption; and
  • The patterns of adopters that lead to meaningful use.

Physicians who take the survey are eligible to win an e-reader.

Compliance Must Be Part of Your Practice

Since 2012, federal health programs, including Medicare and Medicaid, require physicians to establish a compliance plan that can effectively detect "criminal, civil, and administrative violations." That means you must have a process that addresses key compliance issues such as proper coding, medical necessity, and appropriate documentation.

An effective compliance plan can reduce the number of innocent mistakes and will go a long way toward audit avoidance. And, if your practice ends up as the target of allegations, having an effective compliance plan can help your outcome tremendously.

TMA offers a one day seminar, Commit to Compliance: Learn to Build an Effective Compliance Plan, on May 3 at the TMA building in Austin. It will show you how to develop and implement a compliance plan that includes all of the necessary components. The seminar will cover:

  • Coding: documentation guidelines and what triggers an audit;
  • Billing: internal controls and embezzlement protection and billing disclosure requirements;
  • Human resources: federal labor laws for multiple size offices;
  • HIPAA privacy: handling of medical records, myths about HIPAA, and Texas privacy laws, and
  • HIPAA security: rules and safeguards and what's different in Texas.

As a seminar attendee, you will receive TMA's new compliance plan guide, which you can easily customize for any size practice. 

TMA, CMS, Justice Fight ID Theft

Learn how to protect your practice and patients by preventing fraud through identity theft at a two-hour seminar in Dallas on April 17. TMA, the Centers for Medicare & Medicaid Services (CMS), the U.S. Department of Justice, and the Senior Medicare Patrol are sponsoring the seminar.

The seminar, Fraud: Protect Your Practice and Your Patients, begins at 11:30 am in the Dallas Methodist Medical Center's Hitt Auditorium, 1441 N. Beckley Ave. It offers 1 hour of free ethics continuing medical education. Speakers will include CMS and Justice Department officials. 

Registration is required. For more information, email

And if you don't like that topic, time, or place, check out TMA's daylong Commit to Compliance seminar on May 3 at the TMA building in Austin. Effective October 2012, federal health programs, including Medicare and Medicaid, require physicians to establish a compliance plan that can effectively detect "criminal, civil, and administrative violations." Don't get caught unprepared! Attend this seminar to learn how to develop and implement a compliance plan. 



What Can Practice Production Numbers Tell You?

 Consider these factors if your production isn't consistent.

 A practice management tip from
 TMA Practice Consulting 


This Month in Texas Medicine

The March issue of Texas Medicine explains the flaws in the Medicaid 1115 waiver program, explores the concept of publishing physician fees, and tells you why Aetna is forking over some cash. It also explains how the Texas Department of Insurance is trashing network adequacy rules and how EHR meaningful use can help patients stop smoking.    

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.

Political Prognosis: Medicaid Expansion, Scope Win Steal Legislative Limelight

While lawmakers scramble to fashion a budget at the halfway mark of the 2013 legislative session, Medicaid expansion remains a focal point. Gov. Rick Perry remains staunchly opposed as pressure mounts on state leaders to find a way to expand the program using billions of dollars available under the Patient Protection and Affordable Care Act (PPACA).

Meanwhile, TMA scored an early win on an agreed-to scope-of-practice bill aiming to improve team-based care.

Early budget drafts also appear to reflect medicine's call to restore many of last session's severe budget cuts. And while medicine makes progress on red-tape reduction, insurance regulation, and public health, TMA lobbyists remain vigilant for battles brewing in these areas and others that threaten the practice of medicine and patient safety.

A Better Budget 
As the House Appropriations Committee and Senate Finance Committee finalized their respective 2014-15 budgets in early March, both chambers added funding for graduate medical education (GME), the Texas Physician Education Loan Repayment Program, women's health care, and mental health care services.        

As this report was prepared, the Senate Finance Committee unanimously passed its version, Senate Bill 1, which would spend $195.5 billion in state and federal money, $94.1 billion of that in state funds.         

GME got a significant boost. Some of the proposed increases include $1.5 million for 10 grants of $150,000 each for hospitals that currently do not have GME; $10 million for GME expansion grants, a new program; $9.5 million in GME formula funding; and doubling of state funding to the Family Medicine Residency Program to $11.5 million.       

SB 1 also adds $230 million for mental health and substance abuse education, treatment, and housing, and community-based programs, among other things. And, an additional $100 million would go toward women's health services, in addition to the $114 million starting point.

The legislature has yet to act on restoring the payment cuts to physicians treating dual-eligible Medicare and Medicaid patients.

Meanwhile, TMA lobbyists remain wary of increased spending for additional fraud inspectors. Senate Bill 8 by Sen. Jane Nelson (R-Flower Mound) essentially codifies controversial Texas Health and Human Services Commission (HHSC) rules that allow inspectors to hold physician payments before proving fraud.

TMA officials are working with the senator to ensure the bill includes due process protections and other safeguards. Because billing varies by specialty, for example, TMA would like to see a fraud review panel that includes physicians to verify fraud allegation before HHSC holds payments.

On Medicaid, the governor has signed an emergency appropriations bill to fund Medicaid and the Children's Health Insurance Program for the remainder of the fiscal year (Aug. 31, 2013). Budget shortfalls last session forced lawmakers to underfund the program by about $4.5 billion.

Medicaid expansion continues to dominate conversations, and related bills have ensued. House Speaker Joe Straus made a recent push for Texas to consider an alternative to the PPACA-prescribed Medicaid expansion that still could bring federal dollars to the state. Meanwhile, House and Senate budget committees heard from HHS Commissioner Kyle Janek, MD, about how various Medicaid expansion scenarios would impact Medicaid caseloads and costs.

House Bill 3791 by Rep. John Zerwas, MD (R-Simonton), authorizes HHSC to strike a compromise with the federal government for a "Texas solution" that might include things like copayments and more tailored benefits, ideas TMA also has recommended.

But Lt. Gov. David Dewhurst was careful to note that because the Medicaid program is broken, the budget passed by the Senate Finance Committee includes a rider "that ensures HHSC would have to seek legislative approval before reforming our Medicaid program, and ensures any proposed changes are consistent with our conservative principles and lowering taxes."

The rider specifically states that "no amount may be expended to modify Medicaid eligibility unless the commission develops a plan to create more efficient health care coverage options for all existing and newly eligible populations."

Federal officials oppose Republican-backed ideas of giving states a block grant to do as they please, while Governor Perry faithfully refuses to fully expand the current program. "Those are the two guardrails we are operating between, and somewhere in the middle is a solution" for expansion to work in Texas, said Darren Whitehurst, TMA vice president for advocacy.

TMA continues to call on leaders to find a Texas-based solution that first fixes the current broken Medicaid system by increasing physician payments and reducing hassles like unfair fraud-and-abuse investigations, and then uses expansion money in a way that makes care available to more Texas patients.

For more on TMA's approach, see "Expand Medicaid, But Fix It First" by TMA President Michael E. Speer, MD.

Also see "Fix it First," in the April issue of Texas Medicine.

Crackdown on Silent PPOs, Red Tape
The House Insurance Committee took up a number of bills TMA hopes will crack down on insurance shenanigans and red tape.

Physicians testified in support of House Bill 620 by Rep. Craig Eiland (D-Galveston), which would for the first time regulate "silent PPOs," companies or health insurance networks that sell, lease, or share physician-negotiated discounts without doctors' knowledge or consent. The legislation has the support of TMA, the Texas Pediatric Society, the Texas Academy of Family Physicians, and Blue Cross and Blue Shield of Texas. Sen. Charles Schwertner, MD (R-Georgetown), carries the companion bill, Senate Bill 822.

House Bill 1032 by Representative Zerwas requires all insurers and health benefit managers to use a standard prior-authorization request form for prescription drug benefits. TMA lobbyists say Aetna alone has dozens of different forms. The Texas Department of Insurance would create the new standard form with stakeholder input. Sen. Joan Huffman (R-Houston) sponsors the Senate version, Senate Bill 644. The legislation also has the support of several Texas specialty societies and pharmacy associations.

Meanwhile, TMA continues to monitor a number of so-called pricing transparency bills aiming to collect data on health care pricing and quality that could create additional hassles for physicians without any clear impact on costs or quality. 

As part of TMA's red-tape reduction effort, House Bill 1803 by Rep. Bill Callegari (R-Katy) streamlines the Department of Public Safety process for renewing physicians' controlled substance permits and makes it concurrent with medical license renewals. Senator Huffman filed the companion bill, Senate Bill 1805. On March 14, the Senate passed Senate Bill 166 to allow physicians to use the electronic strip on the back of a patient's driver's license to speed up check-in time and increase medical records accuracy.

Keep Nonphysicians Out of Medicine
TMA also is working to defend against government dictates and scope-of-practice infringements on medicine and the patient-physician relationship.

The House Public Health Committee took up House Bill 446 by Rep. Dawnna Dukes (D-Austin) requiring physicians to tell pregnant patients during their first prenatal visit about the risks of drinking alcohol and fetal alcohol syndrome (FAS). Physicians must document that they counseled the patient and must provide a brochure. The patient also must indicate she received the information. TMA opposes the bill on the grounds it dictates to physicians how to practice medicine, information on the risks of FAS already is available, and research shows pre-pregnancy screening and counseling is the best prevention.

Also raising a red flag is Senate Bill 97 by Sen. Dan Patrick (R-Houston). It directs physicians to take specific action when prescribing the abortion-inducing drug Mifeprex, including having a contractual arrangement with another physician who agrees to treat any emergencies associated with the drug. TMA does not take a stance on abortion, but opposes the measure because it dictates care standards.

TMA also will battle a host of end-of-life legislation it says could interfere with physicians' ability to write do-not-resuscitate orders and create new liability risks. Instead, medicine is pushing for Senate Bill 303, which doctors say enhances patient autonomy and balances that respect for physicians' moral, ethical, and professional duties to do what's best for patients in their final days. A hearing on the bill is expected soon.      

A number of bills filed would allow nonphysician practitioners to expand their scope of practice, including a slew of chiropractic measures that made it in under the wire.

House Bill 1039 (Representative Eiland) would give physical therapists direct access to patients without first seeking a diagnosis warranting the care. TMA and specialty groups, including orthopedic surgeons, oppose the bill.

Physicians are going on offense to support House Bill 1782 to require nonphysicians to wear photo identification disclosing to patients their level of training, education, and licensing. Some practitioners with doctoral training have proclaimed themselves "doctors," which TMA says could mislead patients to think a physician is treating them.

Racing toward the finish line is Senate Bill 406 by Senator Nelson. The agreed-to legislation by TMA, the Texas Academy of Family Physicians, and nurse and physician assistant groups replaces current site-based restrictions for prescriptive delegation and supervision with a more flexible model that still preserves diagnosing and prescribing as the practice of medicine.

Senator Nelson told Texas Medicine she is confident the bill will make it through the legislative process. The bill unanimously passed the Senate this month. Read more in the May issue of Texas Medicine.

On public health, TMA and the Texas Public Health Coalition (TPHC) took steps to fight obesity by supporting a bid by Sen. Carlos Uresti (D-San Antonio) to prohibit sugary drinks in Texas schools under Senate Bill 317.      

Physicians and the coalition also told the Senate Education Committee to keep the "FitnessGram" program alive in schools so they and their communities can share best practices to address the state's obesity epidemic. Senate Bill 684 by Sen. Bob Deuell, MD (R-Greenville), would make the now-required physical fitness assessments for schoolchildren optional.

As TMA and TPHC push forward on a slew of immunization measures, House Bill 1310 offers a tax break to physicians who bear the cost of storing vaccinations. Watch for a hearing soon.

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



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Last Updated On

January 27, 2016