Action: April 1, 2014

TMA Action April 1, 2014   News and Insights from Texas Medical Association

INSIDE: Congress Patches SGR, Delays ICD-10 

Congress Patches SGR, Delays ICD-10
Aetna Seeks to Axe $120M Ingenix Class Settlement
Take The Physicians Foundation's 2014 National Physician Survey
CMS Proposes New Medicare Advantage Network Rules
TMA Opposes Audiology Scope Expansion
Apply For Meaningful Use Exemption by July 1
OIG Starts Fraud Education Series for Physicians
Attend the Choosing Wisely CME Track at TexMed 

DocbookMD Adds MedPage Today News for Physician Users
The Broadway Tenors Are Playing at TMAF’s 21st Annual Gala!
CME Spotlight Brings CME to Your Inbox
Nominate a Psychiatrist for DSHS Advisory Board
Apply for the Texas Physician Practice Quality Improvement Award
Register for the UT Nutrition Institute Conference
This Month in Texas Medicine

Congress Patches SGR, Delays ICD-10

Congress has done it again. For the 17th time, lawmakers slapped yet another Band-Aid on Medicare to stave off a 24-percent physician payment cut under the fatally flawed Sustainable Growth Rate (SGR) formula. It sets the next SGR cliff for April 1, 2015.

On March 27, the House of Representatives quickly passed HR 4302, the Protecting Access to Medicare Act of 2014, on a voice vote with opposition from the American Medical Association and some other physician organizations. Senate Finance Committee Chair Ron Wyden (D-Ore.) appealed to his fellow senators to consider a permanent fix for the SGR to no avail. The Senate passed the bill the evening of March 31, narrowly averting the drastic physician pay cut set to take place April 1. 

AMA reports that under the bill, the geographic adjustment (GPCI) "floor" of 1.0 for physician work in the Medicare fee schedule would be extended for 12 months. Also, the secretary of Health and Human Services would have discretion to continue suspending recovery audit contractor postpayment audits under the "2-Midnight" policy through June 2015.

To cover the costs of the patch and other provisions, the bill: 

  • Establishes targets of 0.5 percent in savings from "misvalued" Medicare physician payment schedule services from 2017 through 2020, for an estimated savings of $4 billion.
  • Revises the payment system for diagnostic tests and the laboratory fee schedule, based on market-based private sector rates ($2.5 billion).
  • Reduces payments for using CT equipment that does not meet certain dosage standards and implements appropriate use criteria for advanced imaging services ($200 million).
  • Revises the Medicare sequester in 2024 to effectively amplify the sequester's impact on all Medicare providers in that year ($4.9 billion). 

After months of bipartisan progress in both the House and the Senate, this last-minute stall is most frustrating.

From 2003 to March 2014, Congress enacted 16 SGR patches to the tune of $153.7 billion, a total the Texas Medical Association, AMA, and other organizations say far exceeds what it would cost to reform the Medicare physician payment system once and for all. The 10-year cost of bipartisan, bicameral legislation that would have repealed the SGR is $138 billion. 

On the other hand, the measure shows Congress has been listening to what TMA has been saying about the Oct. 1, 2014, mandatory transition to the ICD-10 coding system. Survey after survey document that physicians are nowhere near ready for this ridiculously expensive and unnecessary shift to a brand new coding language. The legislation delays the ICD-10 start date for one year, to Oct. 1, 2015. This represents the second deadline extension for ICD-10. 

Adding to the confusion, the Centers for Medicare & Medicaid Services (CMS) has ordered Medicare contractors like Novitas to hold physicians' claims for two weeks after the April 1 deadline.

In a March 28 email notice to health professionals, the agency stated the claims hold would only affect 2014 Medicare Physician Fee Schedule claims with dates of service of April 1, 2014, and later and "should have minimal impact on provider cash flow, because under current law, clean electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the date of receipt."

CMS noted "all claims for services delivered on or before March 31, 2014, will be processed and paid under normal procedures."

Aetna Seeks to Axe $120M Ingenix Class Settlement

Late last year, Aetna Inc. announced a proposed class settlement of up to $120 million over its use of the flawed Ingenix database. The settlement covered physicians and health care professionals who delivered out-of-network services to Aetna subscribers any time between June 3, 2003, and Aug. 30, 2013, and received less than the billed charge.

The U.S. District Court in New Jersey planned to consider final approval of the settlement at a March 18 hearing. Less than one week before the hearing, Aetna notified the court it was invoking a provision of the settlement that allowed it to terminate the agreement if settlement claims of health professionals and subscribers opting out exceed $20 million. 

Aetna told the court, "Based on the list of opt-outs provided by the settlement administrator to Aetna and class counsel, the opt-out levels exceed the threshold." Aetna did not provide specific numbers.

Attorneys for the plaintiff physicians are determining whether Aetna has properly terminated the settlement. If that is the case, the class action lawsuits against Aetna will proceed to trial.

Physicians who've been practicing medicine since 2003 and delivered out of network care to Aetna subscribers may be able to join as class representatives. If you wish to join the amended lawsuit, please email TMA Vice President and General Counsel Rocky Wilcox, or call him at (800) 880-1300, ext. 1335. 

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.

UnitedHealthcare entered into a $350 million class settlement in 2009 for out-of-network underpayments. Aetna, United, and other insurers agreed to stop using the Ingenix database as part of the settlement, which created FAIR Health to take over and improve the database and establish transparent, current, and reliable health care charge information.

For additional information about the settlement, visit the Aetna UCR settlement website.

Take The Physicians Foundation's 2014 National Physician Survey

Let your voice be heard! Complete the 2014 National Physician Survey, sponsored by The Physicians Foundation, a nonprofit organization that works to improve physician satisfaction. The foundation's third national survey gives you and your colleagues a chance to comment on the current state of the medical profession in what may be the most comprehensive survey of American physicians ever undertaken.

Your responses to the survey will help The Physicians Foundation provide a state of the union of the medical profession to policymakers, political leaders, and the public so that the physicians' perspective can command the attention it deserves.

And here's a bonus: When you take the survey and include your email address, you'll be entered into a drawing for a $10,000 travel voucher, a $2,000 Apple voucher, or an iPad Air. Plus, participants who provide an email address will receive a copy of the full survey report.

CMS Proposes New Medicare Advantage Network Rules

The Centers for Medicare & Medicaid Services (CMS) recently announced it is considering new rules aimed at safeguarding Medicare Advantage enrollees when health plans significantly reduce their physician networks. 

The CMS announcement follows UnitedHealthcare's termination of thousands of Texas physicians from its Medicare Advantage plans last fall. The insurer's actions had national implications.

Connecticut's Fairfield County Medical Association and Hartford County Medical Association sued United after the organizations learned the insurer began removing physicians from its Medicare Advantage network in October. The American Medical Association and TMA filed supporting amicus briefs in the case. For more on the lawsuit, read "A Bitter Pill." 

TMA officials say the legal action and subsequent media coverage helped spur CMS to act. 

CMS is considering requiring Medicare Advantage organizations to provide:

  • Enrollees at least 30 days' notice of significant network changes;
  • Health professionals at least 60 days' notice of a contract termination; and 
  • CMS regional office account managers at least 90 days' notice before the effective date of significant changes to provider networks. 

According to CMS, notification would allow for coordination between the Medicare Advantage organizations and their account managers "to ensure that affected providers and enrollees receive timely notification of such changes." The 90-day advance notice also would help CMS ensure the Medicare Advantage organizations "will continue to meet required network standards if the planned network changes are implemented." The rules could be finalized as early as April 7. 

     TMLT Action Ad 4.13  

TMA Opposes Audiology Scope Expansion

Audiologists lack the "medical training necessary to perform the same duties as physicians" and aren't able to "provide patients with the medical diagnosis and treatment options they require." That's the message TMA, the American Academy of Otolaryngology – Head and Neck Surgery, 38 state and local medical associations, and dozens of specialty societies and national organizations sent in a letter to House and Senate leaders.

The groups strongly oppose HR 4035 by Rep. Jim McDermott (D-Wash.) and S 2046 by Sen. Sherrod Brown (D-Ohio), saying they give audiologists unlimited, direct access to Medicare patients without a physician referral. Representative McDermott introduced the resolution in the House in February at the request of the American Academy of Audiology.

The letter acknowledges audiologists play a crucial role as valuable members of the physician-led health care team but states that "aspirations of some audiologists to independently diagnose hearing disorders transcends their level of training and expertise."

TMA and the organizations that signed on to the letter implore lawmakers "to oppose any efforts to advance this ill-advised legislation" for the sake of America's senior citizens.

Apply For Meaningful Use Exemption by July 1

Physicians who are not participating in the Medicare electronic health record (EHR) incentive program, also known as meaningful use, will be penalized by Medicare beginning Jan. 1, 2015. To prevent the penalty, physicians must either attest to meaningful use by Oct. 1, 2014, or apply for a hardship exemption by July 1, 2014.

Physicians who meet the following criteria are automatically exempt from the program and do not need to file an exemption application: 

Specialties: If you're classified in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) as one of these five specialties, you don't need to file an exemption and will be exempt for payment year 2015:  

  • Diagnostic radiology, 
  • Nuclear medicine, 
  • Interventional radiology, 
  • Anesthesiology, and 
  • Pathology. 

New to practice: If you are in your first year of practice, you do not need to claim an exemption. Based on Medicare data in PECOS, the Centers for Medicare & Medicaid Services (CMS) says it will know you are new to practice and will automatically exempt you. 

Hospital-based: If you perform more than 90 percent of services using place of service codes 21 or 23 (hospital), then you will automatically be exempt from the Medicare penalty. 

Other exemptions are available, but you must take the time to fill out the 14-page application and submit it to CMS by July 1, 2014. If multiple physicians at one practice are applying, be sure to include the multiple NPI addendum

You can apply for a hardship exemption if your circumstances fall under one of the following categories: 

  • Infrastructure: You must demonstrate that your practice is in an area without sufficient Internet access to comply with meaningful use and that you face insurmountable barriers to obtain such connectivity. 
  • Unforeseen circumstances: This exemption can be claimed in the case of a natural disaster, closing of a practice, bankruptcy, or if the EHR vendor goes out of business. 
  • Lack of face-to-face patient interactions: If your specialty isn't listed above as exempt and you lack face-to-face interactions with your patients, you can claim an exemption. 
  • 2014 EHR vendor issues: If your EHR vendor was unable to obtain a 2014 certification by July 1, 2014, you should file an application for exemption. 

Exemptions must be renewed annually, and you may not claim an exemption for more than five years.

For more information on penalties and exemptions, please refer to TMA's one-pager. Contact TMA's Health Information Technology Department with questions by email or by calling (800) 880-5370. 

OIG Starts Fraud Education Series for Physicians

The Texas Health and Human Services Commission's Office of Inspector General (OIG) has begun a Provider Education series to inform health professionals on OIG's efforts in detecting, deterring, and correcting fraud, waste, and abuse in the Texas Medicaid system. The first topic is Understanding Waste, Abuse, and Fraud. 

OIG will use the series as a forum to cover such topics as:

  • Defining fraud, waste, and abuse, 
  • Problem areas OIG has identified, 
  • Self-reporting, 
  • The audit process, 
  • Payment holds, 
  • Overpayments, and 
  • The due process rights afforded health professionals. 

If you'd like to suggest a topic for the series, email OIG.

Attend the Choosing Wisely CME Track at TexMed

TMA will offer a continuing medical education (CME) track titled Choosing Wisely: Quality and Patient Safety on Saturday, May 3, from 10 am to 2 pm at the Fort Worth Convention Center during TexMed 2014

The program will include several physician speakers from throughout the state. Each speaker's presentation will highlight the benefits of Choosing Wisely® for different practice settings and specialties. 

The keynote speaker is David H. Johnson, MD, chair of the American Board of Internal Medicine (ABIM) Board of Directors and chair and professor of the Department of Internal Medicine at The University of Texas Southwestern Medical School. Lisa L. Ehrlich, MD, chair of the TMA Health Quality Council, and Frank Villamaria, MD, will cochair the CME program.

Take advantage of the opportunity to ask your questions by participating in a Choosing Wisely in-depth panel discussion.

Visit CME Programming to plan your day at TexMed, or click here to see the full CME database. CME is free with TexMed 2014 registration. 

Choosing Wisely promotes conversations between physicians and patients based on evidence provided by specialty societies that have identified tests or procedures that should be discussed. The ABIM Foundation awarded TMA and its philanthropic arm, the TMA Foundation, a grant to advance the Choosing Wisely campaign among Texas physicians. Support for the grant program comes from the Robert Wood Johnson Foundation.

TMA is looking for physicians who have used the Choosing Wisely lists of recommendations to engage in important conversations with patients to do the right thing at the right time. We want to share with other physicians how this program works for you and your patients. Please contact Hella Wagner at TMA by email or by calling (800) 880-1300, ext. 1403, or (512) 370-1403 to help us tell your Choosing Wisely story.

TMAIT Action Ad 4.13   

DocbookMD Adds MedPage Today News for Physician Users

All TMA member physicians will soon be able to receive breaking medical news from MedPage Today from the DocbookMD app. DocbookMD has partnered with MedPage Today to provide physicians with an instant, trusted news service.

Accessible directly from the DocbookMD menu, you will be able to access an embedded feed of news and articles from MedPage Today to stay abreast of industry trends that interest you and your patients. 

DocbookMD is also now available for your large group or hospital. Physicians within such systems can access a secure, enterprise-wide communication platform that allows them to discuss patient care and share data in real time in compliance with HIPAA. This is the ultimate in fast, efficient, and coordinated communication. 

DocbookMD is an exclusive member benefit, available free in Texas only to TMA members. Across the country, more than 24,000 physicians in 39 states use DocbookMD, further connecting the community of medicine. DocbookMD can be downloaded using the Apple App Store or Google Play.

The Broadway Tenors Are Playing at TMAF’s 21st Annual Gala!

See some of Broadway's best, and enjoy a performance filled with musical hits when you join your colleagues and gala cochairs Dr. Joe and Susan Todd, of Fort Worth, at the TMA Foundation's (TMAF's) 21st gala.

A Masqued Ball is scheduled for Friday, May 2, 2014, at the Omni Fort Worth and will be held in conjunction with TexMed 2014. Don your most festive mask for an evening of revelry fit for a carnival of incognito partygoers, with two guest receptions, a silent auction, dinner, and performances by Soprano Colleen Mallette and The Broadway Tenors. VIP tickets (greater recognition and early entrance) may be purchased for $225, and regular tickets are $175 through April 30.  

New this year is a Scrub Top Silent Auction. Get a preview of this and the regular silent auction on the TMAF website.

Proceeds from the evening's generous donors benefit TMA's health promotion programs including Be Wise ─ ImmunizeSM, Hard Hats for Little Heads, the Ernest and Sarah Butler Excellence in Science Teaching Awards, Choosing Wisely, the Minority Scholarship Program, and more! Proceeds also help fund TMAF's Healthy Now, Healthy Future initiatives including the Champion of Health Award, Medical Community Grants Program, and other local grants to support health improvement projects that join medicine, business, and community in a shared vision of a healthier Texas.

For more information or to purchase tickets, visit the TMAF website, or contact Sean Dunham by telephone at (800) 880-1300, ext. 1664, or (512) 370-1664, or by email.

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

CME Spotlight Brings CME to Your Inbox

Looking for continuing medical education (CME) that is timely and practical? Need help wrapping your head around new rules and regulations? 

The TMA Education Center has it all, adding new webinars, publications, and seminars every month. To find out what's new each month, subscribe to TMA's e-newsletter CME Spotlight. The newsletter brings you a quick summary of new and timely education available to you at special TMA member pricing, with links for more information and easy registration. 

To subscribe, log in to the TMA website, and go to the Subscriptions page. Check "CME Spotlight Newsletter” to find out what's new each month.

Need help? Contact the TMA Knowledge Center by telephone at (800) 880-7955 or by email. 

  PC Action Ad Sept 13      

Nominate a Psychiatrist for DSHS Advisory Board

The Texas Department of State Health Services (DSHS) is seeking physician nominees certified in psychiatry to serve on the department's Medical Advisory Board (MAB). Physicians appointed to the MAB work with DSHS and the Department of Public Safety on determining whether driver's license applicants or current license holders are medically capable of safely operating a motor vehicle. Physician members also review concealed handgun license applications.

MAB meetings occur twice a month in Austin. DSHS requires members to attend approximately six meetings a year, and the department provides $100 reimbursement to board members per meeting attended.

If you'd like to nominate a psychiatrist to serve on the MAB, email the potential nominee's contact information to TMA's Director of Public Health Margaret Mendez by April 18. For more information on the MAB, visit the DSHS website.  

Apply for the Texas Physician Practice Quality Improvement Award

Texas physician practices continue to make great strides in providing reliable preventive services by using health information technology and effective care management methods. If you're among these practices, you should be recognized for your hard work. 

TMA, the TMF Health Quality Institute, and the Texas Osteopathic Medical Association have partnered again to provide the Texas Physician Practice Quality Improvement Award program. 

Learn more about the award program. The online application will be available this month. Practices have until June 13 to apply.

Register for the UT Nutrition Institute Conference

Registration for the second annual University of Texas Nutrition Institute (UTNI) Conference is now open. The theme for this year's event is "Nourish." The conference will take place May 22-24 on the UT-Austin campus at 200 W. 24th St.

Ari Brown, MD, an Austin pediatrician and author of the 411 book series, will be the keynote speaker this year. The conference's emphasis on nutrition research, culinary arts, and wellness makes it ideal for physicians, physician assistants, nurses, and other nonphysician practitioners. 

Award-winning chef David Bull returns this year and will give his popular "flavor profiling" lecture and will teach hands-on cooking classes. He'll also prepare lunch Thursday and Friday. 

Follow UTNI on Twitter for daily updates. Use #UTNI2014 to search for conference information and to post comments and questions.

This Month in Texas Medicine

The April issue of Texas Medicine examines how Texas practices are coping with challenges brought about by the Affordable Care Act, new rules that overhaul residency training accreditation, the impact of patient noncompliance on quality outcomes and physician ratings, the challenges physicians face in giving the HPV vaccine, new DocbookMD features, and a profile of the TexMed 2014 General Session speaker, Zubin Damania, MD.

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.  


HIT: Last Day For First-Year Participants to Begin the 90-day Reporting Period for the 2014 Medicare EHR Incentive Program

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 
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 
4/5        Amarillo 

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Last Updated On

November 09, 2017