TMA Wants Stronger Grace Period Notification
The Centers for Medicare & Medicaid Services (CMS) should require
insurers who offer health plans on the Affordable Care Act exchanges to provide
immediate notice when patients enter the first month of the 90-day grace period.
That's what the Texas Medical Association, the American Medical Association, and
more than 80 state medical societies and specialty organizations told CMS
Administrator Marilyn Tavenner in a letter.
The groups have asked CMS to revisit its policy that allows plans to pend and
deny claims for months two and three of the 90-day grace period, which begins
when patients fail to make a premium payment for a subsidized ACA marketplace
plan. "We further urge CMS to strengthen the requirements for how and when
issuers notify physicians and other providers that a patient who has purchased
subsidized … health insurance coverage has entered the 90-day grace period for
nonpayment of premiums," the letter states.
Physicians have voiced concern over federal rules that put them at risk of
health plans' clawing back any payments made in the second or third month of the
grace period when patients are delinquent on premium payments.
Under ACA, marketplace regulations give patients with subsidized health
insurance coverage three months to pay their premiums and allow health plans to
deny or later recoup payments from doctors for services provided to patients who
are delinquent. The patients must have paid at least their first month's premium
to be eligible for that 90-day grace period.
Federal regulations require exchange plans to notify affected physicians "as
soon as is practicable when an enrollee enters the grace period, since the risk
and burden are greatest on the provider." Notification includes where the
enrollee is in the grace period and the names of everyone covered by the policy.
The notice must tell doctors the health plan may ultimately deny payment. But
federal rules don't specify when or how insurers have to send the
TMA and other organizations call the notice requirements "inadequate" and say
they'll "lead to administrative confusion for physicians and practices." The
groups "urge CMS to require issuers to notify providers of a patient's grace
period status as part of the insurance eligibility verification process."
"CMS has unfairly shifted the burden and risk of potential loss for patient
non-payment of premiums to physicians," the letter states. "This financial
burden will be untenable for many physicians."
AMA plans to develop tools to help physicians navigate the complexities of
the ACA grace period.
TMA Presses SGR Repeal
In a letter to leaders of the U.S. House and Senate, TMA, the
American Medical Association, and more than 600 physician organizations
throughout the nation pressed for passage of legislation by March 31 to "repeal
the fatally flawed sustainable growth rate (SGR) formula." A 24-percent cut to
Medicare payments will occur April 1 if Congress fails to act.
HR 4015 and S 2000, known as the SGR Repeal and Medicare Provider Payment
Modernization Act of 2014, represent a bipartisan, bicameral agreement
"resulting from tireless efforts among the three key congressional committees of
jurisdiction to develop a solution for a problem that has bedeviled lawmakers
for years," the groups said.
Meanwhile, on Wednesday, TMA sent a letter to Texans in Congress. In the letter, TMA President
Stephen L. Brotherton, MD, reminds lawmakers in both chambers, "We’ve made it
this far only because of a bipartisan, bicameral agreement on the need to
replace the SGR."
"Crafting the appropriate health care policy precepts of the bill was the
hard part," he wrote. "Please don't stop here."
To date, Congress has enacted 16 SGR patches to the tune of $153.7 billion, a
total TMA and the organizations that signed on to the letter say far exceeds
what it would cost to reform the Medicare physician payment system once and for
all. The 10-year cost of HR 4015/S 2000 is $138 billion.
"We can no longer afford to spend taxpayer money on stopgap measures that
preserve a failed policy," the letter from the 600 medical associations
The groups state in the letter that the Medicare Provider Payment
Modernization Act includes health care delivery and physician payment reform
recommendations from the physician community. It also calls for significant
resources and tools to help physicians transition to new payment and delivery
The letter concludes by imploring Congress to "quickly seize the opportunity
to take advantage of this work and momentum to finally break the SGR status quo
and pass a long-term solution."
TMA urges member physicians to contact U.S. Sens. John Cornyn and Ted Cruz
and their U.S. representative through the TMA Grassroots Action Center. A separate alert is available for patients to use.
Attest by April 1 for Medicaid Primary Care Pay Increase
To qualify for the full Medicaid primary care physician payment increase
authorized by the Affordable Care Act, eligible physicians must submit an attestation form by April 1. Physicians who submit a
form before April 1 will be eligible for retroactive payments from Jan. 1, 2013.
Physicians who attest after the deadline will receive only retroactive payments
from the date Texas Medicaid & Healthcare Partnership (TMHP) received the
If a physician's attestation has a postmark before the deadline, TMHP must
honor it, even if the form contains errors or omissions. TMHP has posted an
updated list of physicians who have successfully attested as of Feb.
18. Additionally, TMHP recently posted a list of Frequently Asked Questions and Answers regarding the
The health care reform law grants a rate increase for certain primary care
physicians and their services from Jan. 1, 2013, through Dec. 31, 2014. To
receive the higher payments, physicians must self-attest that they practice in
an eligible specialty and that either:
- They are board certified in family medicine, general internal medicine,
pediatric medicine, or are a subspecialty within those designations as
recognized by the American Board of Medical Specialties, the American
Osteopathic Association, or the American Board of Physician Specialties, or
- Sixty percent of their Medicaid billings for the prior year were for
eligible evaluation and management (E&M) services. Those eligible services
are E&M codes 99201 through 99499 and services related to the administration
of vaccines (90465, 90466, 90467, 90468, 90471, 90472, 90473, and 90474).
Physicians who submitted a form but are not on the list should contact the
TMHP call center at (800) 925-9126.
In March, Medicaid HMOs began paying supplemental payments to physicians who
had successfully attested by Oct. 16, 2013. Initial payments are for eligible
services provided in the first quarter of 2013.
For physicians who completed the attestation process between mid-October and
mid-February, HMOs will begin issuing retroactive supplemental payments in late
April. Once the initial supplemental payments have been made, HMOs will begin
issuing periodic payments for all remaining eligible services provided through
April 2014. Thereafter, payments will be made on a quarterly basis.
The interim payment schedule will vary by HMO, so please contact the plans
with which you contract for additional details. Please note that supplemental
payments don't currently include vaccine administration fees or Texas Health
Steps services billed by a group practice. Payments for those services must
still be calculated and will be paid at a later date.
In April, TMHP will begin issuing supplemental payments for eligible
fee-for-service claims retroactive to Jan. 1, 2013.
If Texas Medicaid inaccurately calculated a claim or omitted a claim from
payment, please contact TMHP.
Medicare End-to-End Testing Accepting Volunteers
Ready to test ICD-10 with Medicare? The Centers for Medicare & Medicaid
Services (CMS) will select volunteer clearinghouses and physicians to
participate in end-to-end testing of ICD-10 the week of July 21-25. The deadline
to volunteer is March 24.
CMS will enlist more than 500 volunteer physicians, clearinghouses, and
providers nationwide for the testing. Novitas Solutions, like its sister
Medicare administrative contractors, will be allowed to select 32
physicians/providers from Jurisdiction H.
End-to-end testing encompasses submitting test claims to CMS with ICD-10
codes through receiving a remittance advice that explains the adjudication of
the claims — hopefully all successfully.
If you use a clearinghouse, encourage your vendor to volunteer for the
testing (you might even forward this notice). If you have the ability to submit
claims directly to Novitas and want to volunteer, complete the Volunteer Testing Form. You'll receive more information if you
Find more information about testing at MLN Matters No. SE1409 Revised and about volunteering at
MLN Matters No. MM8602 from CMS.
If you have any questions, contact Novitas Solutions at (855) 252-8782.