TMA Action March 14, 2014   News and Insights from Texas Medical Association 

INSIDE: TMA Wants Stronger Grace Period Notification 

TMA Wants Stronger Grace Period Notification
TMA Presses SGR Repeal
Attest by April 1 for Medicaid Primary Care Pay Increase
Medicare End-to-End Testing Accepting Volunteers
TMA Releases 2nd Edition of NPP Guide
Supreme Court to Review Antitrust Enforcement Case
Virtual ICD-10 Training in Your Office 

Rule Gives Patients Access to Lab Reports
Register for the Texas Health Home Summit Today
TMA Knowledge Center Helps With Board Certification
Need a Cancer Expert? TMA Can Help
March Madness Tips Off Hard Hats Giveaways
This Month in Texas Medicine

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 notification.

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 states.

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 models.

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 attestation. 

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 supplemental payments.

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 are selected.

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. 

TMAIT Action Ad 4.13      

TMA Releases 2nd Edition of NPP Guide

Last year, the Texas Legislature passed legislation that replaces site-based requirements for the delegation and supervision of prescriptive authority for nonphysician practitioners (NPPs) with a framework of delegation and supervision that uses customizable prescriptive authority agreements.

To reflect these recent changes in legislation, TMA has released an updated second edition of the best-selling publication Nonphysician Practitioners: Hiring, Billing, and Delegation of Duties for a Nonphysician Practitioner. The publication provides the most up-to-date, comprehensive information about the qualifications, supervision requirements, and practical aspects of contracting, credentialing, and billing for nonphysician practitioners. Click here to order the publication. 

The prescribing of drugs and devices is a large part of the practice of medicine. While you may delegate the prescribing and ordering of drugs or devices to NPPs when appropriate, you must always supervise any delegation appropriately in accordance with the standard of care.

Supreme Court to Review Antitrust Enforcement Case

The U.S. Supreme Court announced March 3 that it will decide whether a federal agency can second-guess the work of state medical licensure boards.

The nation's highest court will hear North Carolina State Board of Dental Examiners v. Federal Trade Commission (FTC), a case in which a federal appeals court ruled in favor of the FTC's claim that state licensure boards should be subject to antitrust laws. The appeals court's decision could potentially strip these boards of their authority to regulate their health care professions and shield patients from unlawful practice. 

In a petition filed in late November, the Litigation Center of the American Medical Association and State Medical Societies and other medical groups urged the Supreme Court to consider the case. The petition argued that "the public is best served when state regulatory boards … are free to make decisions on public health issues without fear of second-guessing under the federal antitrust laws." 

AMA and other petitioners expressed concern over the case's "chilling effect" on medical boards, as the FTC could use federal antitrust laws to second-guess the board's actions on issues related to scope of practice and unlawful practice.

Visit the AMA website for more information on the FTC's engagement with state legislators and state boards of medicine. Read "Doctors Targeted" in the August 2012 issue of Texas Medicine for more on the case.

Virtual ICD-10 Training in Your Office

With ICD-10 preparation well under way and the transition date less than eight months away, it's time to determine how the new coding system will fit into your practice's daily operations. How does your current documentation stack up to the new guidelines, and what changes do your staff members need to make to their standard workflow to ensure a seamless transition and steady payment flow? Your practice's success is in the details.

TMA's new seminar, streaming live over the Internet March 18, will train you and your staff in ICD-10 documentation and auditing. It will cover navigating the expansive ICD-10 CM code book, the new coding guidelines, and avoiding denied claims through proper documentation and audit methods.

The live streaming seminar gives you the opportunity to ask questions and interact just as you would in person but without the travel. To register, visit the TMA Education Center or call (877) 880-1335. 

     TMLT Action Ad 4.13

 Rule Gives Patients Access to Lab Reports

Patients no longer have to call their physicians to get the results of a lab test under a new federal rule that gives them direct access to the reports. 

The Department of Health and Human Services (HHS) action amends earlier federal requirements that patients access their lab tests through their physicians. Patients can continue to do so, but the new flexibility "gives patients a new option to obtain their test reports directly from the laboratory, while maintaining strong protections for patients' privacy," HHS announced in February. 

Under certain circumstances, individuals designated by or personally representing the patient also can see or obtain a copy of the patient's protected health information, including an electronic copy. 

The final regulation acknowledges concerns that a number of physicians and laboratories expressed during rulemaking about giving patients a way to receive laboratory test reports "without the benefit of provider interpretation and without contextual knowledge that may be necessary to properly read and understand the reports." 

For example, physicians and labs cautioned that patients might receive and act upon results that appear to be abnormal — such as showing false positives or false negatives — or results that are out of the normal range for the general population but may be normal for that particular patient due to his or her medical conditions.

But HHS Secretary Kathleen Sebelius said "information like lab results can empower patients to track their health progress, make decisions with their health care professionals, and adhere to important treatment plans." Supporters, such as consumer advocacy groups, agreed the change would give patients the chance to play a more active role in their health care and have more informed conversations with their health care professionals, resulting in better health outcomes.

HHS officials pointed to studies showing physician practices sometimes fail to inform patients of abnormal test results, "resulting in a substantial number of patients not being informed by their providers of clinically significant tests results." But those studies show that happens only about 7 percent of the time.

Register for the Texas Health Home Summit Today

Join your colleagues for the second annual Texas Health Home Summit May 8-9 at the Westin Austin at The Domain to learn about medical home models and best practices and to interact with experts at various stages of medical home implementation. Register, and access fee information online.  

Presented by the Texas Medical Home Initiative and the Texas Health Institute, the event will focus on integration of behavioral health into the health home and on health homes for children and adolescents. TMA is a sponsor of the event and a planning committee member.

The summit encompasses: 

  • An understanding of the medical home and how it promotes accessible, continuous, and culturally effective health care.
  • Awareness of best practices to improve the medical home for all types of patients.
  • Knowledge about how state and federal legislation impacts medical home implementation.
  • Tools that can be used in the clinical practice or community to promote the medical home.
  • A focus on consumer engagement and strengthened partnerships between families, health professionals, and the health care system. 

Continuing medical education credit information for the summit will be announced soon.

TMA Knowledge Center Helps With Board Certification

Does your board certification process require journal articles? The TMA Knowledge Center can help you by obtaining articles and performing custom research requests. 

Call the TMA Knowledge Center at (800) 880-7955, or send an email to get started.   


 PC Action Ad Aug 13      

Need a Cancer Expert? TMA Can Help

Are you looking for a speaker on the latest in cancer control and prevention? The TMA Cancer Speakers Bureau is here to help.

The bureau, a TMA Committee on Cancer project, is made up of volunteer cancer experts throughout Texas who can speak to physicians and other health care professionals on: 

  • Primary prevention and risk reduction;
  • Cancer screening and early detection;
  • Diagnosis, treatment, and palliation; and
  • Quality of life and survivorship. 

If you're interested in another cancer-related topic, TMA can seek out speakers to meet your needs. To request a speaker for your next event or educational program, contact TMA at least 60 days in advance via email or by calling the TMA Knowledge Center at (800) 880-7955.

March Madness Tips Off Hard Hats Giveaways

Spring is an ideal time to help Texas children be active and safe through TMA's Hard Hats for Little Heads bike helmet giveaway program. Sponsor a local giveaway in 2014 to help Hard Hats for Little Heads celebrate 20 years of keeping kids safe. 

TMA is running and gunning to give away its 200,000th helmet this year. The goal: Give away 34,000 helmets. That's 10,000 more helmets than TMA usually gives in a year. We need your help to make it happen.

Whether you see children in your practice or just want to keep kids safe, you can give free helmets in your community. March, April, and May are three key months to get in the game: Brain Injury Awareness Month, Texas Child Safety Month, and Bike Month. 

Hosting a giveaway is easy. TMA provides all you need — helmets and promotional and educational materials. For the first 50 helmets you purchase, TMA gives you another 50 helmets free. Helmets are $7.35 each, including shipping.

Schedule your giveaway today. Find event ideas and much more in the Hard Hats event toolkit. Email TMA's outreach coordinator or call (800) 880-1300, ext. 1470, or (512) 370-1470 to learn more about hosting an event.

Hard Hats for Little Heads is made possible through a grant from TMA Foundation thanks to top donors — Blue Cross and Blue Shield of Texas, Prudential, and two anonymous foundations — and generous gifts from physicians and their families and friends of medicine. 

This Month in Texas Medicine

The March issue of Texas Medicine illustrates how financial forecasting leads to success in medical practices. It also delves into continuing problems with Novitas, UnitedHealthcare's termination of physicians from its Medicare Advantage plans, patient satisfaction surveys, and results of a survey that gauges legislators' perceptions of obesity-related topics.. 

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.   

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.  

Medicaid: EHR Incentive Program Attestation Deadline for 2013 Participation   

Medicare: EHR Incentive Program Attestation Deadline for 2013 Participation

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. 


ICD-10 Documentation and Auditing 
3/18      Austin 
3/19      Lubbock 
4/1        Tyler 
4/2        Dallas 
4/3       Wichita Falls 
4/8        Fort Worth 
4/9-10  Houston 

On-Demand Webinars

Dealing with Difficult Patients 
Making Discussions About Death and Dying Easier 
Meaningful Use: Information Technology Bundle  


5/2-3    Fort Worth  

Physician Health & Wellness, ext. 1342

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

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