Action: Sept. 17, 2013

TMA Action Sept. 17, 2013      News and Insights from Texas Medical Association            

INSIDE: Aetna to Pay $120 Million in Claims Dispute


Aetna to Pay $120 Million in Claims Dispute
National, State Lawmakers to Address Fall Conference
Hey Doc, TMA Answers Your Patients' Health Insurance Marketplace Questions
Give Employees Insurance Exchange Notice by Oct. 1
Not Doing PQRS? Quick Action Will Avoid a Penalty
CMS Sends Home Health Reports
Use CHIP Patients' New IDs Oct. 1 or Later … or Else
Is Your EHR 2014 Certified?
TMA's Live ICD-10 Seminar Under Way
Preceptorship Program to Accept Applications
This Month in Texas Medicine

Aetna to Pay $120 Million in Claims Dispute

Aetna's creation of a $120 million fund to pay physicians for out-of-network claims moved closer to reality last month when a New Jersey federal judge tentatively approved a settlement of the class action lawsuit by the Texas Medical Association and its organized medicine partners. Final approval is scheduled for March.

The $120 million will come in two parts. Half will cover claims from physicians and patients who qualified to be parties to the case but do not have the documentation to show how much Aetna owes them. It also covers attorneys' fees and administrative costs. The second will pay claims from physicians and patients who have the documentation.

The agreement, which was reached last December, calls for a settlement administrator to officially notify physicians of the settlement by Dec. 28. The notice will tell physicians what they need to do to file a claim. Claims must be submitted by March 28, 2014. The settlement applies to physicians who were out-of-network providers "at any time" from June 3, 2003, through Aug. 30, 2013, the date the judge preliminarily approved it, and whose claims were not paid in full by Aetna.

TMA, the American Medical Association, and the medical societies of California, Connecticut, Florida, Georgia, North Carolina, New Jersey, New York, Tennessee, and Washington sued Aetna in 2009 over its use of databases licensed from Ingenix, a UnitedHealth Group Inc. subsidiary. Ingenix underpaid physicians for out-of-network services, the lawsuit said. It also challenged other ways Aetna determined out-of-network payment rates and accused Aetna of failing to disclose how it figured those rates. A patient filed a similar suit in 2007.

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.

National, State Lawmakers to Address Fall Conference

The patient-physician relationship will be the focus of the TMA Fall Conference, Friday and Saturday, Oct. 18-19, at the AT&T Conference Center in Austin.

Saturday's session begins at 7:30 am with a Dawn Duster session on TMA's new Physician Services Organization for Patient Care.

The general session begins at 8:45 am with remarks by TMA President Stephen Brotherton, MD. U.S. Sen. Ted Cruz (R-Texas) will follow with an update on issues in Congress.

Next on the agenda will be a panel discussion on Protecting the Patient-Physician Relationship. Panel members will be state Reps. Susan King (R-Abilene), Sarah Davis (R-Houston), and Nicole Collier (D-Fort Worth).

The session ends with a recap of the 2013 legislative session by Evan Smith, chief executive officer and editor-in-chief of the Texas Tribune.

You can get your flu shot and other vaccinations recommended for health care professionals at the conference. Physicians and their families, medical students, and office staff can get a vaccination Saturday, Oct. 19, from 7:30 to 8:30 am. The event is sponsored by TMA's Committee on Infectious Diseases and TMA's Be Wise — ImmunizeSM program. 

Flu shots, including the new quadrivalent vaccine, and flu mist will be available. You also can get a Tdap (tetanus, diphtheria, and pertussis) or MMR (measles, mumps, and rubella) vaccination.

The cost for a flu shot is $27; for quadrivalent vaccination (limited supply), $40; for FluMist, $40; for Tdap, $80; and for MMR, $105.

Be Wise — Immunize is a joint initiative led by TMA physicians and the TMA Alliance, funded by the TMA Foundation through generous grants from H-E-B and the TMF Health Quality Institute. Since the program began in 2004, more than 235,000 vaccinations have been given to Texas children, adolescents, and adults.

Be sure to reserve your vaccination when you register for the conference.

TMA councils, boards, committees, and sections will meet during the conference.

Book your hotel reservation by Sept. 26 to receive a discounted room rate.

Be Wise — Immunize is a service mark of the Texas Medical Association.  


Hey Doc, TMA Answers Your Patients' Health Insurance Marketplace Questions

"Hey Doc," TMA's multimedia patient education campaign about the Affordable Care Act (ACA) health insurance marketplace, debuts this week on video, on the Internet, and in the news media. To keep up with the program or to refer your patients, go to


Starting Oct. 1, people can buy insurance from the marketplace to comply with ACA's "individual mandate," which requires everyone to be covered next year. As we roll out the campaign for the public, we will also share the questions and answers with you. Segment 1 – "Introduction, Where to Get Help, When to Sign Up" – is now available .

Remember, though, plenty of questions right now have no answers, have partial answers, or have answers that will change after Oct. 1.

These resources provide details on the insurance marketplace, what to expect, and how to sign up:

  • – the federal government's official website for consumer information on the marketplace and the health care law overall.
  • – another federal resource with explanations, checklists, and official forms, applications, and language materials.
  • Be Covered Texas – an English-Spanish website set up by Blue Cross and Blue Shield of Texas to help Texans understand how the marketplace will work here and how to sign up. The site also offers materials such as printable fact sheets on the marketplace and the health reform law and checklists to get ready.
  • Kaiser Family Foundation's (KFF's) State Health Insurance Marketplace Profiles – an interactive map detailing each state's insurance marketplace.
  • KFF's Subsidy Calculator – a tool to help families estimate how much they could spend on health insurance and whether they qualify for financial assistance.     


TMLT Action Ad 4.13      

Give Employees Insurance Exchange Notice by Oct. 1

Open enrollment for coverage through health insurance exchanges (also called the health insurance marketplace) begins Oct. 1, 2013. You must give notice of such, in writing, to your employees by that date.


The U.S. Department of Labor (DOL) has released two model notices you can use to satisfy this requirement, as applicable:

The notice reminds employees of their health insurance coverage options. If your practice is subject to the Fair Labor Standards Act (i.e., if your annual dollar volume of business is $500,000 or more), you are subject to this notice regulation. All active employees must get this notice before Oct. 1, and all new hires after Oct. 1 must receive it within 14 days of their hire date.

A new Model COBRA Notice also is available from the DOL's Affordable Care Act website for use after Oct. 1, 2014.

If you have questions, contact the TMA Knowledge Center at (800) 880-7955 or knowledge[at]texmed[dot]org.  


Not Doing PQRS? Quick Action Will Avoid a Penalty

For practices not current participating in the Medicare Physician Quality Reporting System (PQRS), and who don’t want to use a qualified registry or electronic health record (EHR) PQRS reporting mechanism, another Medicare penalty is looming. Take action now to sign up for a temporary mechanism to prevent it.

Practices not participating in PQRS in 2013 will pay a 1.5-percent penalty on their Medicare claims in 2015. The Centers for Medicare & Medicaid Services (CMS) has created an option — for 2013 only and if you sign up by Oct. 15, 2013 — that allows practices to participate in PQRS and avoid the penalty just by signing up — no quality reporting required (and no eligibility for PRQS incentives, either).

But don’t delay. Signing up is a multistep process, and practices are already reporting significant delays in getting their sign-up approved and completed through the Medicare system.

Here's an outline of what you need to do: 

Step 1: Get a new IACS* account or modify an existing account as soon as possible at Individual physicians are identified in IACS by their taxpayer identification number (TIN) and National Provider Identifier (NPI). Groups (defined as two or more eligible professionals) are identified by their TIN. Individuals who bill under the group's TIN do not have to get an IACS account or register for PQRS individually. 

  • If you/your group already has an active IACS account: You must add a PV-PQRS Registration System "role" (i.e., designate a person as PQRS representative) to the account.
  • If you/your group is creating a new account: You must designate one person to be the IACS account representative and request approval from CMS. This is where the delay is occurring. Once this role is approved, the representative can designate the PQRS representative within IACS (can be the same person).

Step 2: Register in the PV-PQRS Registration System at using your IACS user ID and password.

Step 3: Choose as your reporting mechanism the administrative claims-based reporting option. Under this temporary reporting mechanism, CMS will automatically analyze all your Medicare claims to find out if you performed a designated set of clinical quality actions (see Tables 123 and 124) over the reporting year. A zero performance rate in any of these actions will not count against you. By signing up for this reporting option so that Medicare can analyze your data, you will not be penalized in 2015 for not participating in PQRS in 2013.

  • Under the administrative claims-based reporting option, you do not have to submit specific quality data codes for PQRS measures, like you do with traditional PQRS reporting via registry, EHR, or claims.
  • You will not earn PQRS incentives for reporting through this option; you will only avoid the future penalty.

 Additional Options

 It is too late to report via claims if you haven't already started. However, you still can choose to report for 2013 via registry or EHR.

  • The submission deadline for the PQRS Wizard registry is March 13, 2014. For Covisint Docsite, the submission deadline is March 1, 2014. Learn about TMA's discounted rates for these registries.
  • You have until Feb. 28, 2014, to submit data via a qualified EHR PQRS reporting mechanism. Find out from your EHR vendor if this capability is incorporated into your EHR or is an add-on service.
  • Group practices of 100 or more eligible professionals also can elect to be subject to value-based payment under a quality-tiering calculation.

 More Information

  • Find out more on the CMS website about signing up for the CMS-calculated claims option.
  • For help registering on IACS and the PV-PQRS Registration System, refer to these detailed instructions from CMS. In addition, the CMS QualityNet Help Desk at (866) 288-8912 is open 7 am-7 pm CT, or you can email gnetsuppor[at]sdps[dot]org. Expect long wait times.
  • Listen to a short podcast about PQRS 2013 dates from the American College of Physicians.
  • Learn more about PQRS at If you have questions, call the TMA Knowledge Center at (800) 880-7955.

*Individuals Authorized Access to the CMS Computer Services  



CMS Sends Home Health Reports

The Centers for Medicare & Medicaid Services (CMS) sent physicians Comparative Billing reports on home health services. The reports contain peer comparisons that give you insights into your coding and billing practices through tables and graphs that compare your billing and payment patterns to your peers both statewide and nationally.


Physicians receiving these reports should review the rules for home health certification.

To certify home health services for a patient, you must have (and document) a face-to-face encounter with the patient within 90 days of the start of home health care. In addition to the actual face-to-face visit, the physician must specifically document that the face-to-face encounter has occurred.  This "documentation" must meet specific requirements.

CMS posted a lengthy list of questions and answers about its home health care requirements on its website. TMA's Payment Advocacy Department recommends you review them.

Novitas has additional information on its website.    


 TMAIT Action Ad 4.13   


Use CHIP Patients' New IDs Oct. 1 or Later … or Else

Patients in the Children's Health Insurance Program (CHIP) are receiving new identification (ID) numbers that physicians must use to bill for services provided on or after Oct. 1. That's because the Texas Health and Human Services Commission (HHSC) placed CHIP cases in the Texas Integrated Eligibility Redesign System (TIERS).


The new CHIP ID will be a nine-digit number (not an alphanumeric) TIERS will recognize. Physicians should confirm whether the patient is enrolled in CHIP or Medicaid because the new ID is similar to a Medicaid ID number, HHSC said. You can call the CHIP Provider Line at (800) 645-7164 to verify eligibility of CHIP and CHIP perinatal clients, or you can contact the patient's health plan.

HHSC added that physicians must use the old alphanumeric CHIP ID for services provided before Oct. 1, with one exception: CHIP perinatal patients who enrolled on or after Sept. 3, 2013, already have received the new ID number, and physicians should immediately begin billing using the new CHIP ID number.

If a practice does not use the appropriate CHIP ID number to bill services, the claim will be denied.  However, physicians can appeal a claim denial using the standard appeals process.

For questions, email  CHIPintoTIERS[at]hhsc[dot]state[dot]tx[dot]us.  



Is Your EHR 2014 Certified?

All electronic health record (EHR) users must upgrade their systems before attesting to meaningful use under Medicare for the 2014 payment year. It does not matter whether they attest to Stage 1 or Stage 2 of meaningful use.


Regardless of the stage of meaningful use they are trying to meet, they must use a Stage 2-certified product in 2014.

Some EHR vendors already have released Stage 2-certified versions of their product. You can check the certified health product list (CHPL) to see if your vendor has upgraded. Certification ensures the product has all the necessary capabilities, functionalities, and security required so that physicians can successfully attest to meaningful use.

During attestation, the Centers for Medicare & Medicaid Services (CMS) requires you to give CMS an EHR Certification ID for the EHR technology you use to demonstrate meaningful use. EHR products that do not meet all of the CMS-required criteria to demonstrate meaningful use will not have a CMS EHR Certification ID. To get the certification ID for your product, view the instructions about using the CHPL website.

If you need assistance with the EHR incentive program, turn to 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. 

View a list of upcoming state and federal health information technology (HIT) compliance deadlines and related resources on TMA's Deadlines for Doctors.

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



TMA's Live ICD-10 Seminar Under Way

Has your practice started ICD-10 implementation? Knowing exactly what needs to be done in all areas of your practice is imperative to transitioning successfully, but putting your plans into action is the only way to actually get it done. 


TMA's Achieving ICD-10 Implementation Success seminar series is already under way, but it's not too late to register and get the knowledge and practical skills needed to implement ICD-10 in your practice.

This is your last opportunity to register for the seminar to receive live, interactive training on how to have a successful and efficient ICD-10 transition. Only nine seminar dates remain, so register yourself and your staff today. 


 PC Action Ad Sept 13

Preceptorship Program to Accept Applications

The General Internal Medicine Statewide Preceptorship Program (GIMSPP) will begin accepting applications on Jan 7.


If you are a student interested in applying for a preceptorship or a physician willing to be a preceptor next summer, email Claire Foster or call her at (800) 880-1300, ext. 1523, or (512) 370-1523. 

GIMSSP places medical students with general internists across the state for two-, three-, or four-week preceptorships during the student's summer break to attract medical students to careers in general internal medicine. First- and second-year students from all nine Texas medical schools participate in the program.

For more information and answers to frequently asked questions, visit the program website.



This Month in Texas Medicine

The September issue of Texas Medicine marks the 10th anniversary of tort reform with an examination of how it has lowered your liability premiums, brought more doctors to Texas, and improved patients' access to care. You can also read about optimism that the Sustainable Growth Rate may be on its way out, the new TMA-won law against "silent PPOs," and how physicians are working to reduce maternal deaths. And, you'll find out what the Bridges to Excellence program is all about and learn what a "doctorpreneur" is.

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. 

Live Seminars

Achieving ICD-10 Implementation Success

Physician Health and Wellness, Ext. 1342  

Getting Older: Beats the Alternative!
9/20-21 Montgomery

Healthy Physicians: Healthy Patients
10/26 San Antonio



Last Updated On

January 27, 2016