| TMA Action July
|| News and Insights from Texas Medical
INSIDE: TMA Opposes Nurse Practitioner Plan
TMA Opposes Nurse
TMA to VA: Texas Docs Are Here to Help
TMA Wants Medical Aid for
Central American Refugees
TMA Calls for Meaningful Use Moratorium
Ordering/Referring Edits Extended to Certifying Physicians
TMA Weighs in on Public
Health, Medicaid Funding
TMA Members Testify on DSHS, UIL Sunset
Claims Paid Promptly With TMA Live Webinar
Need Ethics CME? Make PHW Your No. 1
Physicians Foundation's 2014 National Physician Survey
Timely Communication for
ACOs With DocbookMD
Docright Helps TMA Members Compare EHRs, Other
in Texas Medicine
TMA Opposes Nurse Practitioner Plan
Proposed new rules regulating the scope of practice of
advanced practice registered nurses (APRNs) would illegally allow APRNs to make
medical diagnoses, and the proposed rules ignore key tenets of a new state law,
TMA and nine other state medical societies wrote in a formal comment letter to the Texas State Board of Nursing
"Throughout the proposed rules APRNs are given the authority to 'diagnose'
medical conditions, yet the Texas Occupations Code … expressly defines
'professional nursing' as not including the acts of medical diagnosis," TMA
President Austin I. King, MD, and representatives from the Texas Academy of
Family Physicians (TAFP), the Federation of Texas Psychiatry, the Texas
Ophthalmological Association, the Texas Orthopaedic Association, the Texas
Osteopathic Medical Association, the Texas Pain Society, the Texas Pediatric
Society, the Texas Society of Anesthesiologists, and the Texas Society for
Gastroenterology and Endoscopy wrote in the letter to TBN. "Medical diagnosis is
not among the acts that may be delegated by a physician to a nurse under any
The 2013 Texas Legislature — with the strong support of TMA, TAFP, the Texas
Academy of Physician Assistants, and the various organizations representing
APRNs — passed a law that changed the regulatory structure related to physician
delegation of duties for APRNs and physician assistants (PAs). It affected
physician delegation and supervision of prescribing privileges and increased the
number of PAs and APRNs to whom a physician could delegate. Senate Bill 406 also
gave physicians a great deal of leeway in managing their teams of midlevel
practitioners according to their style of practice and the needs of their
"When performing those delegated acts, the standards that should be adopted
are those of medicine, not nursing," the organizations wrote in their letter.
The proposed rules "require APRNs to adhere to standards of nursing practice set
forth in the rules and to standards of nursing practice as stated by national
professional nursing associations recognized by the TBN. Two medical practice
standards or 'schools of medicine,' one for APRNs (when operating under a
physician's delegated authority) and one for physicians should not be the result
of these proposed rules. Only one school of medicine is supported by the Texas
Constitution and the Texas laws authorizing delegation."
The new law gives the physician the authority to decide what acts to delegate
to an APRN or PA for a reason. "Due to the limited training and experience
required in the abbreviated programs leading to licensure of APRNs (as compared
to the required education and training of licensed physicians), it is the
delegated physician who must assess the education, training, experience, and
competence of each APRN to determine the appropriate amount and type of
delegation of medical services," the groups wrote.
TMA routinely fights actions of state agencies that would illegally expand
the scope of practice of nonphysician practitioners.
"This is just one more example of nurse practitioners trying to obtain
through rulemaking what they were unable to get from the Texas Legislature, and
it goes well beyond the bill they agreed to," said TMA General Counsel Donald P.
"Rocky" Wilcox. "We remain vigilant to protect the safety of Texas
TMA to VA: Texas Docs Are Here to Help
TMA President Austin King, MD, announced the registry of private physicians
willing to see patients in the Veterans Affairs (VA) health care system in a
letter to the director of every VA hospital, clinic, and veterans center in the
"As the Department of Veterans Affairs health care system works to overcome
the recently documented access-to-care problems, I am writing to tell you that
the physicians of Texas are here to help you and the veterans you serve," Dr.
King wrote. Already, more than 200 TMA-member physicians have signed up for the
The action came after the American Medical Association House of Delegates, at
the urging of Texas physicians, voted overwhelmingly to ask President Barack
Obama to provide timely access to entitled care for eligible veterans through
the health care sector outside the VA system until VA can provide care in a
timely fashion. AMA immediately fired off a
letter calling on the president to "take immediate action" to clear the way
for private-sector physicians to help reduce the VA backlog.
If you haven't signed up for the registry, please go to the TMA website and
check the "I am willing to
serve veterans" box.
TMA Wants Medical Aid for Central American Refugees
The Central American women and children streaming into South Texas need
medical assistance, and they need it now, says TMA President Austin King, MD,
who traveled to McAllen to personally survey the crisis.
TMA is calling on President Barack Obama and Gov. Rick Perry to provide
medical aid to the thousands of women and children who have traveled from
Central America to Texas. Many of these children have traveled alone without an
adult, while others have entered the United States with their mothers. The
children traveling with their mothers often have a relative or friend in the
United States awaiting their arrival and can get through the immigration process
faster. They then disperse throughout the country using public transportation
without knowing their immunization status and without a physical exam or health
history by a physician.
Texas physicians want to ensure every child and mother is vaccinated and
receives a thorough health examination — and soon. Dr. King explained,
"Communicable diseases know no borders, and it’s critical we make certain no one
is traveling with tuberculosis, pertussis, measles, or any other contagious
disease. Medical aid not only protects the Central American refugees, but it
also protects U.S. residents from potentially serious and deadly diseases.
“Taking care of these oppressed people who have traveled days without food,
water, or bathing is the humanitarian and right thing to do. By helping them, we
also are helping our own residents stay healthy,” added Dr. King.
TMA Calls for Meaningful Use Moratorium
Because physicians "are feeling overloaded by the myriad new Stage 2
meaningful use measures imposed on them," Congress should stop Medicare from
requiring any new meaningful use criteria, a TMA leader wrote in a letter to the chair of the U.S. House Energy and Commerce
Otherwise, Matt Murray, MD, the chair of TMA's Ad Hoc Committee on Health
Information Technology, wrote to U.S. Rep. Fred Upton (R-Mich.), "Texas
physicians — out of frustration — will withdraw from the Meaningful Use program
at alarming rates."
The letter also praised Chairman Upton for demanding answers from the
National Coordinator for Health Information Technology about the future
regulatory burden on physicians' use of electronic health records (EHRs). "TMA
strongly recommends that the Centers for Medicaid & Medicare Services (CMS)
or Congress suspend the EHR penalties on Medicare charges that are scheduled to
take effect Jan. 1, 2015," Dr. Murray added. "We believe CMS will put patient
safety at risk by requiring EHR vendors to meet overly burdensome certification
requirements and physicians to implement complex EHR upgrades in a compressed
period of time."
Physicians with questions related to the EHR meaningful use program can
contact TMA's Health Information Technology Department by calling (800) 880-5720
or emailing HIT@texmed.org.
Medicare Ordering/Referring Edits Extended to Certifying Physicians
Beginning July 1, the certifying physician reported on a Medicare home
health agency (HHA) claim must be enrolled in Medicare. If not, the claim will be denied under
Medicare's ordering and referring denial edits.
Previously, these edits applied only to the attending physician on an HHA
claim. Starting with home health episodes that begin on or after July 1, the
edits will check to ensure both the attending and certifying physicians (when
they are different people) have valid national provider identifiers (NPIs) and
are eligible to order and refer the HHA items and services. Both physicians must
be enrolled in the Medicare Provider Enrollment, Chain and Ownership System
(PECOS) — or have validly opted out — as of the date of service. You can verify if a physician is listed in PECOS on the Centers for
Medicare & Medicaid Services (CMS) website.
An attending physician signs a patient's plan of care, while a certifying
physician certifies or
recertifies a patient's eligibility to receive services under the Medicare
home health benefit.
- If the certifying and attending physicians are different, both physicians
are subject to the ordering and referring denial edits. These edits apply to the
"Attending" and "Referring Provider" fields in electronic claims. In paper
claims, the "Other Provider" field identifies the certifying physician.
- If the certifying and attending physicians are the same, the edits apply
only to the "Attending" field.
For more information, see the following from CMS:
TMA Weighs in on Public Health, Medicaid Funding
Last week, TMA submitted comments regarding the 2016-17 legislative
appropriations request from the Texas Health and Human Services Commission (HHSC) and the Texas Department of State Health Services (DSHS).
TMA encourages DSHS to invest in immunization services, chronic disease
prevention, preventive care for low-income women, mental health services, and
In regard to chronic disease prevention, TMA states, "We support DSHS'
efforts to promote community-based initiatives to increase physical activity and
access to healthy foods in Texas communities." The association adds, "DSHS has
been successful in identifying many potentially preventable hospitalizations. If
given appropriate resources, the agency could better foster community engagement
to help reduce the many conditions related to chronic diseases, such as
pneumonia, diabetes, and heart failure, all of which are endemic across
TMA's comments conclude: "We know DSHS faces a difficult task assigned by the
Legislative Budget Board, especially when the state's public health system is at
a breaking point. We would welcome the opportunity to further discuss any
potential cuts and steps that might be taken to avoid such action and/or
In the comments to HHSC, TMA urges the agency to prioritize improving
Medicaid patients' access to services, including women's health care. The
association specifically asks for support for maintaining the Medicaid primary
care physician payment increase and for continued funding of the Texas Women's
Last session, the legislature provided $71.3 million for the Texas Women's
Health Program, operated by HHSC. Ninety percent of the dollars replaced federal
funding for the Medicaid women's health program, which Texas discontinued in
2012 because of its "affiliate ban rule," which excluded from the federal
program clinics affiliated with abortion providers. The Texas program provides
low-income women aged 18 to 44 with access to birth control, basic preventive
health screenings, and treatment for sexually transmitted diseases.
"While the investments made in the Texas Women's Health Program in 2013
increased the number of women served, tens of thousands of low-income Texas
women still lack access to care. The state must work to maintain or increase the
funding for this valuable program to help rebuild the women's health care safety
net and ultimately save the state millions in Medicaid dollars," TMA said.
The Affordable Care Act authorized increasing Medicaid payments to Medicare
parity for certain primary care physicians and services provided from Jan. 1,
2013, to Dec. 31, 2014.
"Without congressional action, the rate increase will cease at the end of
this year. We urge the state to permanently extend the rate increase beyond Dec.
31, 2014. It is vitally important to increase the number of physicians
participating in Medicaid so that access is not hindered and Texans can get the
care that they need," TMA wrote.
The association also calls for an increase in Medicaid payments for physician
specialties not included in the ACA primary care payment increase, including
obstetrics and gynecology.
TMA Members Testify on DSHS, UIL Sunset Review
Two TMA member physicians testified June 25 before the Senate Committee on
Health & Human Services on the Sunset Advisory Commission's Staff Report on the Texas Department of State Health
Services (DSHS). And Houston neurologist Kim Monday, MD, provided preliminary
comments on the University Interscholastic League (UIL) sunset review.
TMA Trustee Gary Floyd, MD, testified that TMA agrees with the Sunset Advisory
Commission's recommendation to reduce the size and footprint of DSHS. "To
achieve this, we agree shrinking the regulatory tasks of DSHS is needed," he
Dr. Floyd expressed concern over the commission's proposal to eliminate
licensure of medical physicists, radiologic technologists, perfusionists, and
respiratory therapists from DSHS operations.
"Each of these health care providers has a specialized and unique role in
patient care and is a valuable member of the health care team," he said, adding
"an appropriate state licensure process [should] be in place to ensure each and
every professional group is maintaining its qualifications and upholding
standards of practice."
TMA opposes placing any health care profession within the Texas Department of
Licensing and Regulation (TDLR), stating the department "does not have
appropriate leadership, resources, or background in health care policy or public
health matters." In the testimony, Dr. Floyd suggested the Texas Medical Board
(TMB) as an alternative, should it be impossible to keep the licensure and
regulatory functions of these health professionals in their current
And William S. "Chip" Riggins Jr., MD, executive director of the Williamson
County and Cities Health District, testified
on DSHS' management of the state's public health system. Overall, TMA agrees
with the Sunset Advisory Commission that Texas has a fragmented public health
Dr. Riggins called for a "deliberate, more comprehensive focus on Texas'
public health infrastructure," adding that "lack of statutory clarity leaves
DSHS with little ability to influence standards and basic level of services
provided by local health departments."
In her testimony on UIL's sunset review, Dr. Monday agreed with
sunset staff recommendations regarding steroid testing. "TMA supports science
and evidence-based testing and recommends a full review of current testing
programs, such as the steroid testing initiative. The review should assess
cost-benefit and scientific value as well as the depth of illegal steroid use in
Texas athletes," she said.
Dr. Monday also addressed TMA's concerns over the Sunset Commission's lack of
attention to the required pre-participation exam for Texas athletes and
recommended the UIL dedicate additional resources to collecting aggregate data
on injuries among athletes.
Get Claims Paid Promptly With TMA Live Webinar
Since their inception in 1991, Texas' prompt pay laws have helped ensure
commercial health plans pay a practice's clean claims promptly and
Texas law provides for payment no later than 45 days after the date a health
plan receives a nonelectronic clean claim and no later than 30 days after
receipt of an electronic clean claim. But many physicians are still dealing with
payment hassles and finding it necessary to divert practice resources to get
paid what the plans owe.
On July 15, during the noon-1 pm lunch hour, a new live TMA webinar will address prompt pay issues as they
relate to your practice and your revenue cycle and will instruct you on how to
put yourself in a position of advantage to enforce the prompt payment of your
Prompt Pay and the Revenue Cycle — Part I (July 15) discusses
the following concepts:
- The relationship between Texas prompt pay laws and your revenue cycle;
- Contract terms that affect your ability to enforce prompt payment of your
- The importance of collecting and tracking specific patient insurance
information to support prompt pay enforcement; and
- The impact of your practice fee schedule and charge capture on prompt pay
Part II of the series will discuss the Texas prompt pay laws in the context
of your claim-submission process, accounting for patient responsibility and
insurance receipts, practice management system setup, and appeal or
reconsideration. Registration for Part II will open soon.
Need Ethics CME? Make PHW Your No. 1 Stop!
The TMA Committee on Physician Health and Wellness (PHW) offers several live
presentations on request, as well as online and home study courses, all of which
are accredited for AMA PRA Category 1 Credit™ and designated for ethics
and/or professional responsibility education.
- Live presentations: Choose from 24 courses to have presented by a PHW
education team member at your county medical society, hospital, or other
- Online courses: You may access PHW courses online via the TMA Education Center, which allows for the electronic
completion of continuing medical education (CME) courses. Courses are all PDFs,
so one click takes you to the primary document to read. Then complete the test
and evaluation, and upon successful completion, you are able to access your CME
transcript online. Choose from 19 courses in one-hour and two-hour formats.
- Home study courses: All of the online topics are available for home study.
Read the PDF course, then complete the TMA identification page, test, and
evaluation. Send the completed documents to TMA with your administration fee,
and TMA will send a CME transcript to you.
When you need CME and/or ethics credits, make PHW your No. 1 stop. Contact
TMA PHW Committee staff at (800) 880-1300, ext. 1342, to request a live
presentation or home study course.
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
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
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.
Timely Communication for ACOs With DocbookMD
Participation in accountable care organizations (ACOs) is a growing
movement, due in part to their potential to overcome some of the rising costs
(and hurdles) of current health care delivery. To achieve optimal patient
outcomes and lower costs for patients and physicians, ACO networks must be able
to communicate in a timely manner to coordinate care between independent
physicians and large groups. The solution at the center of this communication
network is DocbookMD.
DocbookMD has a unique ability to support ACOs because it is a communication
platform that connects physicians directly to their medical colleagues, care
teams, and other health information technology (IT) resources. Thus, it acts as
a hub for the disparate systems ACO participants currently have in place.
Whether it's different electronic medical record systems, health information
exchanges, or other health IT, DocbookMD allows all participants to communicate
and share patient information in real time — even if they have no other IT
solutions in place. This added efficiency ultimately drives down the cost of
DocbookMD has recently partnered with one of the largest ACOs in the country
— Memorial Hermann Physician Network of Houston (MHMD). MHMD physicians will
gain significant communication and workflow advantages and be able to securely
connect to one another, as well as to other physicians across Houston.
DocbookMD is available to all TMA members as a free member
benefit. Across the country, more than 25,000 physicians in 41 states use
DocbookMD, further connecting the community of medicine. DocbookMD is available
for iPhone, iPad, and Android devices, as well as PC and Mac. The app can be
downloaded using the Apple App
Store or Google Play.
Docbook Enterprise offers a scalable and secure way for
groups, hospitals, and ACOs to meet a wide variety of workflow needs and enhance
existing technology systems. To bring the Enterprise version of DocbookMD to
your hospital or large group, contact DocbookMD Director of Partnerships Chad
Shepler by email
or phone, (512) 383-5822.
Docright Helps TMA Members Compare EHRs, Other HIT
Do you need to upgrade or install an electronic health record (EHR) system
but aren't sure where to start?
can help you make more informed decisions about medical technology. The TMA
affiliate gives TMA physician members free access to a comprehensive database of
health care technology products and services.
In the past, the TMA Council on Practice Management Services has not
recommended the association endorse specific EHR products or vendors. Although
the council maintains this position, over the years council members have
recognized the need to offer further assistance to physicians who look to TMA
for help choosing the right EHR for their practices.
TMA members now have exclusive access to Docright's cloud-based system, which
allows physicians to compare EHRs and other health information technology,
interact with technology vendors, and share their technology experiences with
peers. These tools allow physicians to make faster, more informed decisions
about health care vendors and their products and services, in turn reducing
costs, increasing revenues, and improving patient care.
Docright users can see each system's meaningful use ranking, annual sales,
and the year the company started. Physicians can also view key product
information provided by the vendor or easily schedule a product demonstration.
More tools from Docright, including an online request for proposal to assist in
selecting the best technology solutions for your practice, are coming soon.
TMA has developed other tools and resources to assist physicians with EHR
selection, implementation, and meaningful use in lieu of endorsing any
particular product. These include TMA's EHR Product Evaluation
Tool, which is a members-only resource that allows users to view and compare
information on functionality, pricing, and customer and technical support for
the EHR products that represent more than a 3-percent market share in Texas.
Visit the TMA Health Information Technology
Resource Center for more information.
This Month in Texas Medicine
The July issue of Texas
Medicine examines the evolution of telemedicine and addresses a new
Federation of State Medical Boards model policy aiming to create a roadmap for
the safe, appropriate practice of telemedicine. It also informs physicians about
cyber liability insurance, policymakers' price transparency efforts, an
initiative to improve health literacy in the state, and the status of
e-prescribing controlled substances.
to launch the full edition in a new window.
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
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
This Just In ...
Want the latest and hottest news from TMA in a hurry? Then log on to Blogged
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.
Last Day For First-Year Participants to Begin the 90-day Reporting Period for
the 2014 Medicare EHR Incentive Program
Optional Physician and Teaching Hospital CMS Registration Phase
First-Year Participants: Deadline to Attest to Meaningful Use for the 2014
Medicare EHR Incentive Program
HIT: Upgrade EHR for Meaningful Use Stage
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.
Dealing with Difficult
Making Discussions About Death and Dying
Meaningful Use: Information Technology
Prompt Pay and the Revenue Cycle: Part
7/15, noon-1 pm
Physician Health and Wellness, ext. 1342
Physician Well-Being for
Healthy Physicians: Healthy
9/27 El Paso
Action, the TMA newsletter, is emailed twice a month to bring you
timely news and information that affects your practice.
To change the email address where you receive Action, go to Member
Log-In on the TMA website, then click on "Update Your TMA Demographic
Information (including newsletter subscriptions and preferences)."
To unsubscribe from Action, email TMA's Communication Division at email@example.com.
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 Crystal Zuzek,