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.
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
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
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.
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
- 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.
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
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
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
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
- 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
- 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
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
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
"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.