Action: Dec. 16, 2013

TMA Action Dec. 16, 2013   News and Insights from Texas Medical Association 

INSIDE: Congress Moves Toward Temporary Medicare Fee Hike, SGR Repeal

Congress Moves Toward Temporary Medicare Fee Hike, SGR Repeal
2014 Medicare Participation Deadline Extended
Court Keeps Injunction in United Medicare Advantage Case
TMA Answers Your Health Insurance Exchange Questions
TMA: Meaningful Use Delay Not All That Meaningful
Not Using NDC Numbers on Medicaid Claims? Start NOW
Learn to Compete at TMA's Winter Conference 

News From Workers' Comp
Medicaid Seeks Medical Director
Renew TMA Dues Now to Write Off Expense in 2013
Deadline for Grant Funds Approaching!
Second Annual Quality Poster Session at TexMed 2014
Year-End Gifts Keep on Giving!
This Month in Texas Medicine

Congress Moves Toward Temporary Medicare Fee Hike, SGR Repeal

The annual avert-the-impending-Medicare-disaster effort is in full swing as Congress tries to avoid a devastating cut in Medicare payments to physicians caused by the Sustainable Growth Rate (SGR) formula. If that effort does not succeed, physician fees will be cut 23.7 percent on Jan. 1.

But on Dec. 12, as the holiday recess loomed, the House of Representatives approved a three-month, 0.5- percent increase through the end of March. The increase is part of a two-year federal budget agreement the House approved 332-94. The Senate is expected to vote on the measure next week. The agreement sets overall discretionary spending for the 2014 fiscal year at $1.012 trillion and appropriates about $63 billion in relief from budget cuts caused by sequestration over two years through savings elsewhere in the budget. The deal also provides $85 billion in mandatory savings, including about $28 billion over 10 years, by requiring President Obama to sequester the same amount of mandatory budget resources — to Medicare and other programs — for an additional two years through 2023.

Momentum toward repealing the SGR continues to build. Also on Dec. 12, the House Ways and Means Committee and Senate Finance Committee approved legislation replacing the SGR with a payment system that rewards quality over volume. The bill provides 0.5-percent updates for three years, then freezes physicians' Medicare payments for seven years.

 Medpage Today reported that a draft from the two committees says a "value-based performance payment program" would create a single, budget-neutral incentive payment program. Medpage said the draft states that "by combining the current quality incentive programs into one comprehensive program, this proposal would further value-based purchasing within the overall Medicare program while maintaining and improving the efficiency of the underlying structure with which professionals are already familiar."   

 Differences in the House and Senate versions will have to be resolved through negotiations among Ways and Means, House Energy and Commerce, and Senate Finance members and staff. Congress will have to agree on payment levels for physicians. The Senate Finance Committee version maintains the 2013 Medicare payment levels through 2023. 

The Texas Medical Association joined state medical societies in Arizona, California, Florida, Louisiana, Oklahoma, New York, North Carolina, and South Carolina in sending congressional leaders a letter asking them to address several priority issues in the SGR payment reform legislation. The associations make up the Coalition of State Medical Societies, which represents 158,500 physicians and medical students.

The coalition asked Congress to:  

  • Provide positive automatic payment updates,  
  • Eliminate the fee-for-service program penalties, and  
  • Revise or eliminate adoption of the ICD-10 coding system.       

2014 Medicare Participation Deadline Extended

Jan. 31 is the new deadline for physicians to decide whether to participate in the Medicare program in 2014. The deadline originally was Dec. 31, but the Centers for Medicare & Medicaid Services (CMS) extended it because CMS released the 2014 physician fee schedule later than usual. 

You do not have to do anything if you wish to continue participating in Medicare next year.

You have three options in deciding whether to participate in 2014:

  • Sign a participation (PAR) agreement and accept Medicare's allowed charges as payment in full for all Medicare covered services for your Medicare patients.  
  • 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. 
  • Opt out and become a private contracting physician, agreeing to bill patients directly and to forego any payments from Medicare to you or your patients. 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 the affidavit is signed, provided it is filed within 10 days after the physician signs his or her first private contract with a Medicare beneficiary.

Log on to the Novitas Enrollment Center  for more information and links to CMS forms and the online application process.

Court Keeps Injunction in United Medicare Advantage Case

A federal appeals court has refused to allow UnitedHealthcare to continue kicking physicians out of its Medicare Advantage plans. On Dec. 12, the court declined United's request to lift an injunction against the insurer and referred the case to a three-judge panel. The appeals court ordered the parties in the lawsuit to file briefs later this month. 

TMA and other state medical associations had asked the court to keep the injunction in place until the dispute in resolved in the courts.

The lawsuit originated in, and currently applies only to, Connecticut. However, attorneys for TMA and other medical societies are trying to expand the case nationally because physicians in Texas and other states are affected, said TMA Vice President and General Counsel Donald P. Wilcox. For example, he said, TMA has been told 1,100 physicians in Houston were notified they are being terminated.

The brief that TMA and the other associations filed says the appeals court should maintain the injunction because it "temporarily keeps in place the arrangements between United and physicians that have functioned for years." Terminating the physicians will cause them "irreparable harm," but keeping the injunction in place will not hurt United, they said.

United contends the injunction interferes with its right to manage its physician networks.

TMA and the other medical societies told the appeals court the lawsuit serves the interests of their members because "United's improper termination of physicians from the [Medicare Advantage] network would negatively affect other physicians, who would have to bear the burden of serving Medicare patients (at low Medicare rates) who would start coming to them in the absence of their regular doctors. This would place an undue strain on the physicians and practices left remaining in the network, and potentially compromise those providers' doctor-patient relationships with their other patients. In addition, under United's unilateral amendment justification, all physicians in United's networks remain subject to termination at any time and for any of United's products. Thus, in challenging United's use of this method of termination, the associations are protecting all of their members' interests."  

Besides TMA, state medical societies filing the brief included California, Florida, New York, New Jersey, and Tennessee. 

In November, TMA, the American Medical Association, and numerous national specialty societies and state medical associations told the Centers for Medicare & Medicaid Services (CMS) that United and other insurers were terminating physicians from Medicare Advantage plans. They said in a letter to CMS that such insurers are undermining patients' rights and denying them access to care. They asked CMS "to take immediate action" to make sure Medicare beneficiaries participating in these plans "have accurate and reliable information to make health insurance elections during the 2014 Open Enrollment period …"

The letter says hundreds of physicians reported they were terminated from the United Medicare Advantage networks. "The terminations are 'without cause' and have been timed in a manner that undermines the accuracy and reliability of the information Medicare beneficiaries are relying upon in order to make important health care decisions for 2014 health insurance coverage. The timing and process used to communicate the terminations and modifications to the networks are not consistent with CMS guidance and regulations," the letter says. 

They added that the terminations "will disrupt long-established patient-physician relationships, interfere with existing physician referral networks, and undermine emergency department coverage in many hospitals. Both the continuity and coordination of care will be negatively affected, and treatment for certain types of care commonly provided by a very limited number of sub-specialists may no longer be available within the network."

TMA and the others urged CMS to extend the Medicare Advantage open enrollment period and require plan sponsors that have reduced their networks to immediately:    

  • Provide and document that patients received actual and accurate notice of whether their current physicians will be in the 2014 network;    
  • Ensure that patients know they can retain their physician by choosing fee-for-service or by choosing a product with an out-of-network benefit if their plan provides one;   
  • Give physicians information they need to challenge network adequacy based on CMS regulations and extend the appeals deadline until physicians receive such information;    
  • Tell AMA and the state medical societies how many patients are impacted and which physicians were terminated; and  
  • Direct plans to hold all terminations initiated just before or during Open Enrollment 2014.   

TMA Answers Your Health Insurance Exchange Questions

If you missed TMA's live health insurance exchange (HIX) webcast and still have questions about how the Affordable Care Act and the exchange health plans will play out in your practice, you have two upcoming opportunities to view an encore presentation.

On Thursday, Dec. 19, TMA will replay the HIX webcast in its entirety at 7 am CT and again at 5 pm CT. This hour-long discussion led by TMA's Lee Spangler, vice president of medical economics, will help answer the HIX questions you need to ask yourself.

The live program was very well received, and viewers overall awarded very positive assessments:

"This was a very informative webcast and answered most of the questions we have. It also brought up a few topics we hadn't considered yet," said Leah Harlin, a practice administrator in Quitman, Texas.

Register for the 7 am webcast or the 5 pm webcast today to experience the discussion and acquire the information firsthand. A live question-and-answer (Q&A) session will not be a part of the Dec. 19 programs, but you still may submit any HIX questions you have to the TMA Knowledge Center by email or by phone at (800) 880-7955.

Also, be sure also to check out TMA's "Hey, Doc" project for patient information and Q&A videos covering the new health insurance exchange marketplace. 

     TMLT Action Ad 4.13  

TMA: Meaningful Use Delay Not All That Meaningful

The government's decision to postpone Stage 3 meaningful use by extending Stage 2 for a year is not the good news it appears to be, TMA says in a letter to Centers for Medicare & Medicaid Services (CMS) officials. 

"TMA is deeply disappointed that CMS has not recognized the importance of extending the 2014 meaningful use requirements and the start of the penalty period," wrote Joseph Schneider, MD, chair of the TMA Ad Hoc Committee on Health Information Technology. "Many of our members have not yet received their 2014 certified software from their ambulatory EHR vendors. Once they finally receive the upgraded software, it can take many months to test and install, including fixing the bugs that will surely exist as many EHR vendors have rushed this into production. For some, that will leave only the July-September 2014 attestation period for physicians to meet meaningful use and avoid the 2015 penalties."

Dr. Schneider added that TMA "considers this deadline to be dangerous to patient safety and physician practice viability, as Stage 2 requires an enormous change in the management process. Penalizing physicians who take the time to carefully test their software and manage their practices does not indicate an appreciation of patient safety on the part of CMS."

Furthermore, he said, TMA "recommends that physicians be required to meet only a subset of meaningful use measures to avoid the penalty rather than the full set required to receive the incentive. CMS set the precedent of lesser requirements for penalty prevention with the e-prescribing program, which required physicians to e-prescribe 10 times to prevent the penalty and 25 times to receive the incentive. Organized medicine is happy to work with CMS to identify the subset of measures that could be met for penalty prevention."

CMS said it will extend Stage 2 through 2016, and Stage 3 will begin in 2017 "for those providers that have completed at least two years in Stage 2. The goal of this change is two-fold: first, to allow CMS and ONC [Office of the National Coordinator for Health Information Technology] to focus efforts on the successful implementation of the enhanced patient engagement, interoperability and health information exchange requirements in Stage 2; and second, to utilize data from Stage 2 participation to inform policy decisions for Stage 3."  

Dr. Schneider also told CMS that evidence is increasingly clear "that an abrupt switch to ICD-10 on Oct. 1, 2014, will bring massive disruptions to health care. The public and our members are not willing to tolerate these disruptions. We strongly recommend that the period during which either ICD-9 or ICD-10 claims can be filed be extended to Oct. 1, 2016, to give the industry sufficient time to adjust. Failure to address this issue indicates a failure of leadership in Washington."

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

Not Using NDC Numbers on Medicaid Claims? Start NOW   


If you're not already doing so, start including National Drug Code (NDC) numbers on your Medicaid fee-for-service and HMO claims for prescription drugs because Texas will begin enforcing the provision on Jan. 1, 2014. The requirement applies to all outpatient prescription drugs, except vaccines, and to long-acting reversible contraceptives.   

Beginning on Jan. 1,  if a drug manufacturer does not participate in the federal prescription drug rebate program, Medicaid will no longer pay for the drug. TMA requested an extension of the enforcement deadline, but HHSC turned down the request, citing the fiscal implications to the state if it failed to comply by Jan. 1.

A list of rebate program NDC codes is on the Centers for Medicaid & Medicare Services (CMS) website. 

 The Health and Human Services Commission will conduct a webinar on Friday, Dec.  20, from 1 to 2:30 pm CT to discuss the NDC requirement and answer your questions. Registration is required.

The federal Deficit Reduction Act of 2005 requires professional and outpatient hospital claims to include the NDC numbers for physician-administered drugs so that the state and federal governments can increase collections of pharmaceutical rebates. Texas implemented the provision in 2008, though until recently, the provision had not been strictly enforced. An audit conducted by CMS revealed that lack of compliance by Texas had resulted in the state and federal governments losing millions of dollars.

For frequently asked questions and answers about the NDC requirement, a crosswalk of NDC to HCPCS codes, and a link to files containing the NDC number by product, visit the Texas Medicaid & Healthcare Partnership website.    

Learn to Compete at TMA's Winter Conference

The health care marketplace is changing drastically for physicians of all stripes. What new demands will this place on your practice? What is the path forward for physicians who want to remain in private practice? How can physicians in all practice settings protect their clinical and financial autonomy? Join your colleagues at TMA’s 2014 Winter Conference at the Hyatt Regency Austin Jan. 31-Feb 1 to find out how TMA can help you survive and compete in your changing environment. 

 Texas Health and Human Services Executive Commissioner Kyle Janek, MD, along with a panel of physician leaders and legislators, will discuss this new health care transformation during the General Session on Saturday, Feb. 1, from 8:30 to 11:45 am.  

Register for the conference today, and make your reservation at the Hyatt Regency Austin by Jan. 9, 2014, to get the discounted rate of $189. Visit or call (888) 421-1442 to book your room. 

 TMAIT Action Ad 4.13   

News From Workers' Comp

Insurance carriers in the workers' compensation system cannot require injured workers to get their prescriptions filled at pharmacies designated by the insurer, a Texas Department of Insurance official said in a Dec. 9 memo

"Injured employees may fill prescriptions at the pharmacy of their choice as long as the pharmacy accepts workers' compensation," wrote Matthew Zurek, executive deputy commissioner for health care management and system monitoring.

Call the toll-free Comp Connection for Health Care Providers at (800) 372-7713, option 3, or (512) 804-4000 in the Austin area if you need more information.

In addition, the workers' comp system set the 2014 Medical Fee Guideline conversion factors at $55.75 and $69.98. The $55.75 conversion factor applies to service categories of evaluation and management, general medicine, physical medicine and rehabilitation, radiology, pathology, anesthesia, and surgery when performed in an office setting. The conversion factor of $69.98 applies to surgery when performed in a facility setting.

Medicaid Seeks Medical Director

The state's Medicaid and Children's Health Insurance Program is looking for a medical director

The physician will direct medical and dental activities, monitor trends and activities, and make recommendations for improvement. He or she must have graduated from an accredited college of medicine with a degree as a medical or osteopathic doctor, completed residency training and/or practice requirements for board certification, and be licensed as a physician in Texas.

Call (888) 894-4747 for more information.

Renew TMA Dues Now to Write Off Expense in 2013

If you would like to pay your TMA and county medical society dues by the end of the year, please act now to ensure continued access to the many benefits and services available to you.

 Renew online today, take the expense in 2013, and enjoy the difference TMA membership can make to you and your practice. We can accomplish so much when we unite in one voice.

The TMA Knowledge Center can answer your renewal questions by telephone at (800) 880-7955 or by email.  

Deadline for Grant Funds Approaching!

The TMA Foundation (TMAF) is accepting applications to its 2013-14 Medical Community Grants program. TMA county medical societies and alliance chapters may apply for up to $7,500 to support their short-term, high-impact health improvement initiatives. Applications are due no later than Dec. 31.

Get more information and download the applications on the TMAF webpage

  PC Action Ad May 13    

Second Annual Quality Poster Session at TexMed 2014

TMA's second annual Quality Poster Session will take place at TexMed 2014 in Fort Worth in May. You will have the chance to share your successes and breakthroughs in improving patient care with your peers from around the state.  

TMA and TMF Health Quality Institute will host an official continuing medical education presentation 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.

Have a quality improvement success you want to present? Submit your abstract today. First-, second-, and third-place winners will receive special recognition at TexMed 2014 and in Texas Medicine. All selected submissions will receive a modest stipend.

For those not presenting a poster, the Quality Poster Session is still a great opportunity to support your colleagues by taking some time to walk through and see the great things that are happening in the Texas medical community. Poster session attendees will also earn continuing medical education credit and be able to take away some best practices to develop their own programs at home.

Refer to the Quality Poster Session FAQ or email Rebecca Stevens or phone her at (800) 880-1300, ext. 1423, or (512) 370-1423 with any questions you may have.

Year-End Gifts Keep on Giving!

Now is the perfect time to complete pledges and make special gifts to your favorite charities, including the TMA Foundation (TMAF), as these gifts could provide tax savings next April.  Recent changes in the stock market and tax laws mean that it is more important than ever to carefully consider both the timing and form of gifts you make this year, as some gifts can bring even greater benefits. During December, take advantage of these giving options by discussing them with your advisors.  

The TMA Foundation is pleased to share year-end charitable giving ideas with you by sending additional information on how to complete your gifts before the end of the year to receive maximum benefits. Donate online at on the TMAF webpage or call (800) 880-1300, ext. 1664, or (512) 370-1664.

This Month in Texas Medicine

The December issue of Texas Medicine  tells you what Texas medical schools are doing to speed up training of primary care physicians, explains what you need to know about how the new health insurance exchange will affect your practice, and reports on an emergency physician's fight with a hospital over peer review. It also explains why 2014 is a big year for electronic health records and how Medicaid is trying to base payments on quality.

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 Deadlines for Doctors

TMA's Deadlines for Doctors alerts you and your staff to upcoming state and federal compliance timelines and offers information on key health policy issues that impact your practice. 

2013 E-Prescribing Incentives. End-of-year reporting deadline to claim a 0.5-percent bonus  

 EHR Incentive Program Reporting Period Ends for 2013 Payment Year  

 E-Prescribing Deadline for 2013 Incentive

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.  


OSHA Annual Training Webinar
Training on new requirements must be completed by December

Hard Knocks: An Update on Concussion and Texas Law  


TMA Winter Conference
1/31-2/1    Austin

5/2-3    Fort Worth  

Physician Health & Wellness, ext. 1342

Cultural Competence: Putting Patients First  
2/14-15 Fredericksburg 

Healthy Physicians: Healthy Patients 
3/29      Galveston 
4/5        Amarillo    

About Action      

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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