Action: May 15, 2013

TMA Action May 15, 2013         News and Insights from Texas Medical Association       

INSIDE: CMS to Enforce Payment Transparency Law


CMS to Enforce Payment Transparency Law
Aetna Aexcel Ranking Letters Coming
TMA Calculates Impact of Medicare Fee Cut
Start Preparing to Upgrade Your EHR
A Local Solution for ICD-10 Training
Use AT Modifier for Tetanus Shots
You're Eligible for Exclusive Savings!
This Month in Texas Medicine

CMS to Enforce Payment Transparency Law

The Centers for Medicare & Medicaid Services (CMS) will explain the provisions of the National Physician Payment Transparency Act, also known as the Open Payments Act or Sunshine Act, in a teleconference at 1:30 pm CDT on Wednesday, May 22. The act is part of the Patient Protection and Affordable Care Act and requires manufacturers of drugs, medical devices, and biologicals that participate in federal health care programs to annually report payments and items of value they give physicians and teaching hospitals.

The law, which CMS will begin enforcing Aug. 1, also requires manufacturers and group purchasing organizations to report ownership interests held by physicians and their immediate family members. Most of the information contained in the reports will be available on a public, searchable website. Physicians can review their reports and challenge them if they are false, inaccurate, or misleading.

In February 2012, the Texas Medical Association, the American Medical Association, and state and national medical societies across the nation wrote CMS officials a letter expressing concerns with the rule implementing the law and proposing several amendments. The letter said organized medicine believes CMS "exceeded its statutory authority with regard to at least one significant provision and misconstrued Congress' overall intent and statutory requirements in other areas. While we support the underlying goal of enhancing transparency, we believe the proposed rule, if implemented without significant modifications, will result in the publication of misleading information and impose costly and burdensome paperwork requirements on physicians while shedding very little light on actual physician-industry interactions."

As a result, AMA says CMS modified the final regulation so that:


  • Continuing medical education (CME) that complies with certified or accredited CME standards governing independence from industry is excluded from reporting.
  • The time physicians have to challenge inaccurate or misleading reports was expanded. Physicians now may seek corrections and challenge the accuracy of the consolidated reports at any time for two years.
  • If a physician disputes information contained in a report, it will be flagged in the public registry as disputed if the manufacturer and physician do not resolve the dispute.
  • Physicians, teaching hospitals, and industry have six months to prepare before industry is required to begin collecting information on Aug. 1, 2013.
  • Medical residents are excluded from the reporting requirement.


AMA posted a webinar on the law on its website. Physicians Preparing for the Sunshine Act: What You Need to Know and How to Prepare gives a basic overview of the financial interactions and ownership interests that will be reported, the excluded financial interactions, and steps physicians can take between now and Aug. 1. It also lists key dates you need to know and answers frequently asked questions.

Aetna Aexcel Ranking Letters Coming

TMA's Payment Advocacy Department has learned Aetna will begin sending physicians letters informing them of their ranking in its Aexcel network in early June. The rankings take effect Jan. 1.

Aetna has not responded to TMA's questions about how many physicians are affected compared with the last designation.

Current Aexcel program information can be found through Aetna's secure provider website NaviNet. After logging in, select "Aetna Support Center," then select "Doing Business with Aetna." Once here, look for "Aexcel Designation" and you'll find an overview of the designation process, including the evaluation components.

TMA encourages physicians to appeal the Aetna ranking if they believe it does not comply with a state law (House Bill 1888) that TMA persuaded the legislature to pass in 2009. That law requires health plans to conform to nationally recognized standards and guidelines when ranking or tiering physicians. Health plans must give physicians: 


  • Notice of the standards and measures they use before any evaluation period;
  • An opportunity to dispute the ranking before publication;
  • A minimum of 45 days written notice of the proposed rating, ranking, or tiering, including all methodologies and information used;
  • A fair reconsideration process (if timely requested); and
  • A written communication of the outcome of the proceeding before publishing the ranking or tiering.


TMA has developed a Physician Ranking Toolkit to help physicians with the appeals process.   

TMA is tracking this issue. If you appeal, email a copy (please redact any protected health information) to Liz Jero in TMA's Payment Advocacy Department, or fax it to her at (512)370-1632. Also, please notify her of the result of the appeal or any issues that occur.  

TMLT Action Ad 4.13

TMA Calculates Impact of Medicare Fee Cut

Medicare payments to physicians dropped 2 percent on April 1 because of the federal budget sequester. TMA's Payment Advocacy Department analyzed the impact of the fee reduction and compiled a list of answers to questions you may have.

Here is an example of how the fee cut would affect payment for a service with a Medicare fee schedule amount of $100:




Payment Arrangement       Par Physician       Non-Par/Assigned       Non-Par/Unassigned
Total Payment Rate       100% = $100     95% = $95       115% of $95 = $109.25
Amount From Medicare Before April 1     80% of $100 = $80     80% of $95 = $76


Payment From Patient Before April 1       20% of $100 = $20     20% of $95 = $19

80% of $95 ($76) paid by Medicare to patient + 20% of $95 ($19) paid by patient + $14.25 balance bill paid by patient

Amount From Medicare After April 1       80% of $100 - 2% cut = $78.40       80% of $95 - 2% cut = $74.48       $0
Payment From Patient After April 1       20% of $100 = $20
    20% of $95 = $19

80% of $95 - 2% cut ($74.48) paid by Medicare to patient + 20% of $95 ($19) + $15.77 balance bill paid by patient


Total Payment After
April 1  

    $98.40     $93.48




Frequently Asked Questions  

Q: Can I pass on the 2-percent cut to my patients and collect it from them?
A: No.

Q: When will the Centers for Medicare & Medicaid Services (CMS) post an updated 2013 fee schedule based on the 2-percent cut?
A: CMS will not post an updated 2013 fee schedule. The fee schedule you use for 2013 will remain the same.

Q: Will CMS apply the fee reduction to claims processed starting April 1? What if I have a claim from March that hasn't been paid yet?
A: CMS will apply the cut to claims with a date of service of April 1or later. CMS will pay claims from January through March at the posted fee schedule amount without a 2-percent reduction.

Q: Will this cut also impact my payment from Medicare Advantage plans?
A: Possibly. It depends on your contract. If you are out of network with a plan and it pays claims based on the 2013 Medicare Fee Schedule, you will see the 2-percent cut reflected in your payment.

Q: If I'm a Medicare-enrolled physician who is non-par and doesn't accept assignment, do I need to calculate the 2-percent cut off what I collect from the patient?
A: No. You will continue collecting the same amount as you did before. Your patients will see the cut taken on the amount Medicare reimburses them, thus you may receive questions from them.

Q: Will CMS hold claims like it does when the fee schedule undergoes changes?
A: No.

Q:  How is the 2-percent reduction identified on the electronic remittance advice (ERA) and the standard paper remittance (SPR)? 
A:  The Claim Adjustment Reason Code (CARC) 223 is used to report the sequestration reduction on the ERA and SPR.

Q: What is the verbiage for CARC 223? 
A: "Adjustment code for mandated federal, state, or local law/regulation that is not already covered by another code and is mandated before a new code can be created."

Start Preparing to Upgrade Your EHR

Beginning in 2014, all physicians participating in the federal electronic health record (EHR) meaningful use incentive program must use a Stage two-certified EHR. This is true even for physicians attesting for Stage one meaningful use.


There are three planned stages of meaningful use. Physicians who already have met two years of Stage one must attest to meeting the Stage two requirements

Essentially, all EHR users must upgrade their systems before attesting to meaningful use for the 2014 payment year; thus, physicians participating in the meaningful use program in 2014 will only have to meet meaningful use for 90 days rather than the full year, regardless of participation year. Some EHR vendors already have released Stage two-certified versions of their product. Physicians can check the certified health product list to see if their vendor has upgraded yet. 

Physicians needing assistance with the EHR incentive program may receive consulting help from one of four Texas regional extension centers (RECs). The RECs are qualified to help physicians navigate the complexities of the program. Check out TMA's REC Resource Center to find out which REC serves your area. 

For more information about EHRs or other health information technology (HIT) issues, contact TMA's HIT Department at (800) 880-5720 or by email.    


TMAIT Action Ad 4.13  

A Local Solution for ICD-10 Training

Physicians and medical practice staff should work now to make sure employees, office technology, and internal operations are ready to make the switch to ICD-10 on Oct. 1, 2014. However, if you haven't started your preparations or don't know quite where to begin, you're not alone. 

Get TMA's help in starting your transition preparations by attending your area's ICD-10 NOW! How and Why seminar. It gives an overview of ICD-10, why the transition is happening, and offers detailed explanations of how to assess, plan for, and implement the new code set. Everyone who attends will receive a link to TMA's 60-page workbook with practical implementation tools and resources. 

This is an essential seminar for both physicians and staff as ICD-10 will affect every office process. Only the prepared practice will achieve transition success, so register now.

Use AT Modifier for Tetanus Shots

Novitas Solutions says it won't pay Medicare claims for administering tetanus shots that do not have the modifier AT (acute treatment) appended to the code. The medical record must support the need for the service and the use of modifier AT.


Medicare excludes vaccinations unless they relate directly to the treatment of an injury or direct exposure to a disease or condition, such as anti-rabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin sera, or immune globulin. The only preventive immunizations Medicare pays for are pneumococcal, hepatitis B, and influenza virus vaccines. 


 PC Action Ad May 13 

You're Eligible for Exclusive Savings!

I.C. System is celebrating its 75th year with a 20-percent special anniversary discount for TMA members! Call 800-279-3511 or visit I.C. System online for more information on its collection services.


If you haven't tried the Office Depot discount program, now you can save an additional 15 percent off the already discounted prices offered when you place your first order online. Visit TMA's Office Depot page and click on "add coupon" during checkout to enter coupon code 50591873. Click here for more information on this offer.

As a TMA member, you're also eligible to receive all your office and personal magazines at the lowest possible rates. Call (800) 289-6247 for a personal representative who can save you money and provide the best service in the industry. You can browse the large selection of popular titles online.

Visit the TMA website to find more discounts, and start saving today.


This Month in Texas Medicine

The May issue of Texas Medicine outlines the landmark agreement TMA reached with allied health professionals to improve patients' access to care through an improved delegated model for team-based health care, tells you why charging extra fees may cause problems, and explains the federal government’s demands that practices have formal antifraud compliance plans. You’ll also learn why documenting personnel information makes sense and how Medicare bonuses can turn to penalties. Finally, the 2012 Annual Report tells you what TMA did for you and your patients last year.   

Check out our digital edition.


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. 

About Action 

Action, the TMA newsletter, is emailed twice a month to bring you timely news and information that affects your practice. 

To change the email address where you receive Action, go to Member Log-In on the TMA website, then click on "Update Your TMA Demographic Information (including newsletter subscriptions and preferences)."

To unsubscribe from Action, email TMA's Communication Division at

If you have any technical difficulties in reading or receiving this message, please notify our managing editor, Shari Henson. Please send any other comments or suggestions you may have about the newsletter to Larry BeSaw, Action editor.


Last Updated On

January 27, 2016