Act Now to Get Medicaid Fee Increase
Later this year, Texas will increase Medicaid payments to Medicare parity for two years – retroactive to Jan. 1, 2013 – for select primary care services provided by primary care physicians (PCPs) and related subspecialists.
However, to benefit from the fee increase, you must submit a signed self-attestation form to the state's Medicaid claims payer, the Texas Medicaid and Healthcare Partnership (TMHP). The state has not set a deadline for returning attestation forms but will do so in the coming months. (Physicians who return the attestation form after the deadline will not be eligible for increases retroactive to Jan. 1, 2013, though they will be eligible for higher payments through the end of 2014.) If you are eligible, attest early to ensure the state receives your paperwork.
Who is eligible for the higher payments?
Pediatricians, family physicians, and general internists are eligible for the higher payments as are these subspecialists.
To qualify, you must be practicing in an eligible specialty and either board certified or attest that 60 percent of your Medicaid billings are eligible for evaluation and management (E&M) or vaccine administration CPT codes.
Texas Medicaid will conduct a random, statistically valid audit of PCPs receiving the higher payments to ensure they are qualified.
Are advanced practice nurses and physician assistants eligible for higher payments?
Yes. The rate increase will apply to services provided by advanced practice nurses (APNs) or physician assistants (PAs) under physician supervision. APNs or PAs who bill under their own Medicaid Texas provider identification (TPI) number will be paid at 92 percent of the Medicaid payment rate as per current Medicaid payment rules.
What CPT codes are eligible for the higher payments?
Evaluation and management codes 99201 to 99499, including new and established patient preventive care codes and behavioral health counseling codes not covered by Medicare, are eligible. So are vaccine administration codes 90460, 90461, 90471, 90473, and 90474. The higher payments will apply to eligible services provided from Jan. 1, 2013, through Dec. 31, 2014.
How do I attest that I am eligible for the higher payments?
Complete and sign the self-attestation form.
You must complete an attestation form for each individual physician Medicaid TPI number, such as those for Texas Health Steps or multiple practice locations. A group practice may submit attestation forms on behalf of each physician within the practice but cannot attest as a group.
When will higher payments begin, and how will they be made?
Texas anticipates beginning the higher payments in early fall. Eligible claims submitted before the start date will automatically be adjusted retroactively to Jan. 1, 2013, and paid in a lump sum. Thereafter, physicians will receive quarterly payments through the end of the two years.
Once payments begin, HMOs will disburse payments to network physicians for eligible services provided to their enrollees. TMHP will issue payments for services provided to fee-for-service enrollees.
Is the PCP payment increase linked to the state's decision to forego Medicaid expansion to low-income adults as authorized by the Patient Protection and Affordable Care Act?
No. Eligible physicians will be paid the higher fees regardless of whether Texas eventually expands Medicaid.
What is the difference in Medicaid versus Medicare payments?
See this chart showing how the new payments for select CPT codes compare with current payments for Medicaid adult and child services.
The Texas Medical Association will send you updates on the fee increase in Action and post them on the TMA website. For additional help, call the TMA Knowledge Center at (800) 880-7955 or the TMHP Contact Center at (800) 925-9126.
TMA Challenges Dentists' Sleep Apnea Rule
Dentists should not independently diagnose and treat sleep apnea because they are not trained to do so, TMA told officials of the Texas State Board of Dental Examiners.
"It is beyond the scope of practice of dentistry in Texas to diagnose a medical disease or disorder, including a sleep disorder, or to independently treat such disorder once diagnosed," TMA President Stephen L. Brotherton, MD, said in a letter to the board's executive director.
Among TMA's concerns, Dr. Brotherton wrote, is that the dental board is considering adopting a rule that allows dentists to diagnose and treat sleep apnea in collaboration with a physician and that says a "dentist shall ensure that the patient has been evaluated by the physician for a sleep disorder in compliance with the Texas Medical Practice Act and Texas Medical Board rules, and is being monitored by the physician for potential complications of the sleep disorder."
Dr. Brotherton said that language "would not only impose an undue burden on a dentist, but it would require knowledge beyond the scope of a dentist's training or license. A dentist cannot know if a physician is acting in compliance with the Medical Practice Act and Texas Medical Board rules, because a dentist does not practice medicine or have medical training. It would be inappropriate for a dentist to oversee, monitor, or judge a physician's treatment of a patient."
His letter also said other provisions of the rule could be misinterpreted to expand the scope of dentistry.
Supreme Court Lets Scope Ruling Stand
The Texas Supreme Court decided not to review TMA's case against the Texas State Board of Chiropractic Examiners, in which the association argued that chiropractors are not allowed to diagnose. The ruling leaves standing TMA's successful challenge to the board's manipulation-under-anesthesia and needle electromyography regulations. It also has the effect of allowing chiropractors to make a chiropractic diagnosis limited to their scope of practice, as statutorily defined.
TMA is considering whether to continue with its constitutional challenge when it is remanded back to the trial court.
TMA Questions Cigna Red-Tape Hassle
TMA believes a Cigna referral policy imposes a red-tape hassle on physicians and patients and will ask the Texas Department of Insurance (TDI) to determine if the company has violated the agency's network adequacy rules.
Cigna requires physicians and patients to sign a form whenever the physicians refer patients to a non-Cigna network physician or other provider. Physicians must explain on the form why they recommend out-of-network services, must disclose whether they have a financial relationship with the other provider, and must obtain the patient's consent to the referral by having the patient check a box and sign the form. Physicians aren't required to send the forms anywhere but must keep them on file indefinitely.
TMA notified Cigna of its opposition to the requirement two years ago, before TDI adopted network adequacy rules. Earlier this year, TDI granted insurers permission to include contract provisions that require certain disclosures about out-of-network referrals. The rules say insurers can require referring physicians and other health care professionals to disclose ownership interests in facilities or whether the referral is to a person or facility that "might not be a preferred provider."
TMA questions the overly broad approach Cigna is taking on out-of-network referrals and the new rules. The TMA Council on Socioeconomics and the TMA House of Delegates adopted policy opposing such forms and the intrusion into the patient-physician relationship they represent, said Lee Spangler, TMA's vice president for medicine economics.