Action: Dec. 1, 2014

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

TMA Supports OIG Improvements, Stronger Medicaid HMO Oversight
Meaningful Use Audits: Be Prepared
CMS: How to Report Only Once for PQRS, Meaningful Use, Other Programs
Choosing Wisely: CME from TMA
New Toolkit Helps Doctors Navigate Medical Audits
Free Ebola CME from UTHSCSA

2015 TMA Winter Conference: Leading the Way Through Crisis and Change
Searching for the Top Health News of 2014
2014 Healthy Texas Babies Data Book Now Available
AABB Asks for Blood Collection, Use, Management Data
This Month in Texas Medicine

TMA Supports OIG Improvements, Stronger Medicaid HMO Oversight

John Holcomb, MD, a San Antonio pulmonologist and chair of TMA's Select Committee on Medicaid, CHIP, and the Uninsured, testified at the Sunset Advisory Commission last month on proposed changes to the Texas Health and Human Services Commission (HHSC). On behalf of TMA and four other organizations, Dr. Holcomb testified on concerns with Medicaid HMOs and the HHSC Office of Inspector General (OIG). Comments touched on public health matters, as well.

TMA supports sunset recommendations that would further strengthen oversight of Medicaid HMOs and streamline and simplify Medicaid HMO paperwork requirements.

"The expansion of Medicaid HMOs over the past decade corresponds to a simultaneous decline in physician Medicaid participation. When TMA surveys physicians about why they are limiting or leaving Medicaid, the second and third most-cited reasons — after inadequate payments — are mountainous paperwork and convoluted prior authorization requirements, which together are a stranglehold on physicians' willingness to see Medicaid patients. To attract and retain Medicaid participating physicians, Texas must reduce what it costs physicians to participate," Dr. Holcomb said.

In testimony related to OIG's Medicaid fraud and abuse investigations, Dr. Holcomb said "the Sunset staff recommendations build on positive changes the legislature enacted in 2013 to direct the Office of Inspector General to establish fairer investigations." 

A 225-page report on HHSC by the Texas Sunset Advisory Commission says the state's use of freezing payments to physicians suspected of possible Medicaid fraud "has gone beyond the law's intent." The report describes the HHSC Office of Inspector General (OIG) as an agency with poorly trained staff and little accountability or transparency. 

TMA has long championed improvements in the Medicaid system and in OIG's investigations of physicians accused of fraud, waste, and abuse. In comments submitted to the commission, Dr. Holcomb iterated TMA's support for the commission's recommendations "to improve the efficiency and effectiveness of OIG's administrative and investigative processes" and to "clarify OIG's payment hold authority and streamline the CAF [credible allegation of fraud] hold hearing process."

In the comments, TMA outlines its support for the report's recommendations to:  

  • Have a fair administrative process designed to define, detect, and prevent fraudulent and abusive conduct that wastes taxpayer funds;
  • Improve the efficiency of the investigation process, reserve CAF holds for serious situations to mitigate ongoing financial risk to the state, and streamline the administrative appeal hearing process;
  • Include the expertise of medical practitioners with appropriate training and experience in investigations concerning the practice of medicine;
  • Implement quality assurance reviews and consistency in investigations;
  • Clarify organizational oversight and accountability in an effort to ensure OIG is efficiently and effectively accomplishing its mission to combat fraud, waste, and abuse;
  • Better clarify the roles and responsibilities among and between OIG, managed care organizations, and special investigative units; and
  • Require OIG to pay the full hearing costs for CAF hold appeals at the State Office of Administrative Hearings (SOAH). 

TMA and nine other organizations also penned their strong opposition to a proposed 8-percent reduction in Medicaid payments to advanced practice registered nurses (APRNs) and physician assistants (PAs) practicing in a team-based setting. That's the crux of a letter the organizations sent to HHSC last month. The 2013 legislature instructed HHSC to make the reduction as one of many Medicaid cost-containment initiatives. HHSC estimates the change will save more than $14 million. 

TMA and the signatories to the letter tried to stop the measure during the last session to no avail. TMA has been getting phone calls from physicians about the impending cut. 

In the letter, TMA President Austin King, MD, and the others say the 8-percent cut "will undermine Medicaid's efforts to recruit and retain not only these providers, but also physicians seeking to practice in team settings," adding a request that "any such proposal consider the practical impact on team-based practices that voluntarily participate in the Medicaid program and the patients they serve."

The proposed rules state an APRN or PA will be paid 100 percent of the physician fee schedule when the supervising physician "made a decision regarding the patient's care or treatment during the billable medical visit." TMA objects to the phrase "during the billable medical visit" because it "seems to preclude scenarios where the APRN/PA sees the patient, develops/revises a plan of care, then subsequently discusses it with the supervising physician." 

"In such a scenario, the APRN or PA would follow up with the patient after consulting with the supervising physician. As we interpret the proposed rules, the APRN or PA would not be paid 100 percent of the physician fee schedule in this scenario because the consultation did not occur 'during the billable medical visit,'" the letter states.

TMA recommends deleting that phrase "so that team-based practices have more flexibility as to when the supervising physician and APRN/PA can confer." HHSC partially agreed with the recommendation, agreeing to revise the rules to allow the supervising physician to make a documented decision the same date as the billable medical visit.

The letter concludes by stating "exacting an 8-percent payment cut for clinicians at the forefront of redesigning Texas' Medicaid delivery model will stymie practice innovation and ultimately hinder Medicaid HMO efforts to partner with their network providers to implement new models of care."

The new rules will take effect Jan. 1, 2015. HHSC agreed to postpone enforcement until Feb. 1, 2015, to give practices time to update their systems. If the supervising physician did not engage in decisionmaking regarding the patient's care in accordance with the rules, the claims must be submitted with the APRN's or PA's provider identifier or under the physician's number with the appropriate modifier to indicate who provided the care.

Additional details will be posted on the Texas Medicaid and Healthcare Partnership website in December.

Meaningful Use Audits: Be Prepared

TMA is hearing from physicians who are being audited for meaningful use and some who have had their meaningful use incentive dollars recouped. Don't let this happen to you. Remember: Meaningful use is all or nothing. Physicians must meet all measures for successful attestation. This includes conducting a security risk analysis for HIPAA to ensure protection of patient information.

The Centers for Medicare & Medicaid Services (CMS) has indicated about 6 percent of those receiving incentive payments will be audited. If a physician fails an audit and continues to participate, the audits continue before CMS makes another payment. Anyone who receives the incentives could be audited, and recipients should retain all supporting documentation for six years.

TMA has these recommendations to help practices:  

  • Take screen shots of electronic health record (EHR) reports indicating you met a meaningful use measure. If you try to re-create a report at a later date, the EHR may return a different result. 
  • When the meaningful use criteria specify "more than," that doesn't mean "equal to." For example, if the criteria indicate you need to record demographics for more than 80 percent of your patients, then your denominator and numerator should be such that they don't total 80 percent. They must be more. 
  • Keep a meaningful use file (paper or electronic) with all documentation, and know where that file is. Staff turnover could mean the person who created the file is no longer working for you when the audit request comes.  

The Garden City, N.Y., accounting firm Figliozzi & Co. is conducting the audits for CMS. The firm is sending letters asking for documentation supporting the meaningful use attestation. Figliozzi seeks these types of data: 

  • Documentation showing use of a certified EHR system for meaningful use attestation; 
  • Documentation showing completion of the attestation for the core set of meaningful use criteria; and
  • Documentation showing completion of the required number of menu set meaningful use objectives. 

Physicians and others selected for the audits have two weeks to submit their documentation. The audits don't involve site visits. If physicians are ineligible for payment, they may file an appeal through CMS. 

For questions about audits, the incentive program, and other health information technology matters, contact TMA's Department of Health Information Technology at (800) 880-5720 or by email

CMS: How to Report Only Once for PQRS, Meaningful Use, Other Programs

According to the Centers for Medicare & Medicaid Services (CMS), physicians who are beyond their first year of participation in the Medicare electronic health record (EHR) incentive program have the option to streamline their reporting efforts and report quality data only once for several Medicare quality programs. 

In 2014, physicians may submit data one time and receive credit for several Medicare quality programs. Depending on eligibility, physicians and group practices may report on a single set of clinical quality measures (CQMs) as required by meaningful use and satisfy the requirements for: 

  • Physician Quality Reporting System (PQRS),
  • Value-based payment modifier (VM),
  • Medicare EHR incentive program,
  • Medicare shared savings program accountable care organization (ACO),
  • Pioneer ACO, and
  • Comprehensive Primary Care Initiative (CPCI).

Physicians should contact their EHR vendors to discuss this reporting option. To receive credit for these programs, physicians must submit data from Jan. 1 through Dec. 31, 2014. The deadline for submission is Feb. 28, 2015. The CMS website has details about CQMs, including a complete list of the 64 measures and their respective National Quality Strategy domain. 

Physicians who choose to use this method will earn the 2014 PQRS bonus payment and avoid the 2016 PQRS penalty. Physicians also will satisfy the CQM requirements for the other programs, if eligible. 

CMS provides these resources to help you learn how to report data one time for the 2014 program year: 

For more information about the Medicare EHR incentive program, contact the CMS Electronic Health Record Information Center by phone, (888) 734-6433, or visit the CMS website. You can also contact the TMA Knowledge Center by phone, (800) 880-7955, or email.

  TMAIT Action Ad Sept 14  

Choosing Wisely: CME from TMA  

Choosing Wisely® is an initiative of the ABIM Foundation that promotes conversations among physicians and patients to ensure delivery of the right care at the right time. Due to the popularity of the Choosing Wisely continuing medical education (CME) webinars, TMA will continue to offer the CME bundle to members . 

The Choosing Wisely CME webinars were recorded at TexMed 2014, where TMA's Council on Health Care Quality led a continuing medical education track for physicians about the program. TMA, Choosing Wisely, the TMA Foundation, Blue Cross and Blue Shield of Texas, and TMF Health Quality Institute sponsored the CME quality track. 

The Choosing Wisely CME webinar bundle includes five webinars presented by Texas physicians: 

  • Webinar 1: The Choosing Wisely Campaign;
  • Webinar 2: Oncology and Choosing Wisely;
  • Webinar 3: Choosing Wisely Specialist Panel; 
  • Webinar 4: Choosing Wisely Panel Discussion; and
  • Webinar 5: Choosing Wisely — Patient Activation in Safety: Patient Safety Tools. 

Visit the TMA website to register for your CME and learn about the Choosing Wisely initiative and how it can help you. You can earn 3.75 AMA PRA Category 1 Credits™ and 3.75 ethics credits. In addition to the CME webinars, you'll find helpful resources provided by the Choosing Wisely campaign and TMA, such as the full list of recommendations, videos, patient education materials, and more.

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 comes from the Robert Wood Johnson Foundation. 

New Toolkit Helps Doctors Navigate Medical Audits

The Physicians Advocacy Institute (PAI) and the American College of Emergency Physicians (ACEP) collaborated to develop the Toolkit for Physicians Facing Medical Audits, which provides practical information and tips to help physicians anticipate medical audits, respond to auditors’ requests for medical records, and appeal erroneous audit findings. 

The toolkit includes detailed information regarding topics related to medical audits, including the various types of government and private payer audits, appellate procedures, and extrapolation methodologies used by some payers to calculate alleged overpayments.

The toolkit features resources on: 

  • Medical Audits: Top Ten Tips for Physicians to Anticipate, Respond and Protect Their Practices;
  • Tips for Physicians Facing Private Payer and Governmental Audits;
  • Checklist for Physicians Responding to Requests for Medical Records;
  • Checklist for Physicians Appealing Audit Findings;
  • Medical Audits: What Physicians Need to Know; 
  • Preparing for Physician Audits; and
  • The Significance and Implications of the Delay in the Assignment of ALJs (administrative law judges) in Medicare Part B Appeals. 

For information on how your organization can co-brand the toolkit or share the toolkit with physicians via a website or newsletter, refer to: 

In January, PAI and ACEP will host webinars highlighting key aspects of the toolkit's valuable information. If you have questions regarding this toolkit or other PAI resources or activities, email Kelly Kenney.

TMA Executive Vice President and Chief Executive Officer Lou Goodman, PhD, is PAI treasurer, and TMA General Counsel Donald P. "Rocky" Wilcox is chair of PAI's Physician Advocacy Liaison Committee. 

Free Ebola CME from UTHSCSA

The University of Texas Health Science Center at San Antonio is offering an online course titled Ebola Virus Disease: What Should You Know? Update and Demonstration of Donning and Doffing of Personal Protective Equipment. Physicians can earn 1 AMA PRA Category 1 Credit™ free upon completion of the course.

The course focuses on recent Ebola preparedness updates and includes a demonstration of personal protective equipment donning and doffing. This continuing medical education activity is especially relevant to physicians and other health professionals specializing in infectious diseases, internal medicine, emergency medicine, and those involved with the management of Ebola patients. 

Learning objectives include: 

  • Recognition of the epidemiologic risk factors, 
  • Identification of the clinical signs and symptoms, 
  • Understanding the modes of transmission and means of prevention, and
  • Understanding the proper donning and doffing of personal protective equipment.

Register online for this free course. If you need help logging in or have any questions, email cme[at]uthscsa[dot]edu or call (866) 601-4448. 

 TMLT Action Ad 4.13   

2015 TMA Winter Conference: Leading the Way Through Crisis and Change

The 2015 TMA Winter Conference takes place Jan. 30-31 at the Hyatt Regency in downtown Austin. Physicians and medical students will have the opportunity to conduct TMA business, obtain continuing medical education credit, and network with peers. 

Join your colleagues and participate in discussions on crisis management, the current legislative session, and changes in the health care landscape. 

Register and make your hotel reservations on the TMA website.

Searching for the Top Health News of 2014

The TMA Anson Jones, MD, Awards honor outstanding health journalism, and we need your help to find the best stories of 2014. If you've seen, heard, or read an article that caught your attention, nominate it for an award.

TMA family members (physicians, medical students, TMA Alliance members, and county medical societies) can nominate journalists for the Anson Jones awards. Categories cover print, broadcast (television and radio), and online media. Any story from 2014 is eligible.

To nominate a journalist, simply email your nomination: the reporter's name, name of article (if available), date of broadcast/publication, and the media outlet. Please try to include a URL. 

TMA will send the reporter a postcard with a handwritten note. We'll let the reporter know you nominated him or her and for which story or broadcast. 

Visit the Anson Jones webpage for complete nomination details, contest rules, and categories. If you have questions, call Tammy Wishard, TMA outreach coordinator, at (800) 880-1300, ext. 1470, or (512) 370-1470, or email her.

2014 Healthy Texas Babies Data Book Now Available

The Texas Department of State Health Services has released the 2014 Healthy Texas Babies Data Book. This annual publication complements the Healthy Texas Babies initiative and the Texas Collaborative for Healthy Mothers and Babies by providing an in-depth analysis of infant and maternal health in Texas. 

Data help the department identify possible avenues for intervention to improve the health of mothers and infants in Texas. The publication features state-specific information on infant mortality and morbidity, prenatal care, prepregnancy obesity, diabetes and hypertension, and maternal mortality and morbidity. 

 PC Action Ad May 13  

AABB Asks for Blood Collection, Use, Management Data

TMA's Blood and Tissue Usage Committee encourages Texas physicians to complete a new national survey and inform their hospital blood banks about it.

AABB has launched a critical industry-wide survey addressing blood collection, use, and patient blood management. The survey covers the period from Jan. 1 to Dec. 31, 2013. AABB invites interested physicians and hospital blood collection and transfusion services to complete the survey by Dec. 31. 

Based on the data collected, AABB will prepare and distribute a comprehensive report to inform future benchmarking and development of evidence-based programs. Download a PDF of the survey, or contact the AABB Department of Research and Data Analysis for a facility-specific link to the online survey. Direct questions and comments to the toll-free help line at (800) 793-9376 or to hemovigilance[at]aabb[dot]org.

Through your participation, AABB will measure the changes occurring in blood collection and clinical transfusion practices and continue to provide baseline and trend analytics. This survey will build on past biennial national blood surveys. For your participation, you will receive analyzed results, which will allow you to see how your facility stands in comparison to others. The survey takes about 30 minutes to complete once your initial data have been assembled. 

This Month in Texas Medicine

The December issue of Texas Medicine features a cover story on volunteer physicians who answered the call over the summer to care for Central American immigrants crossing the border from Mexico into Texas. In the latest issue, you'll also read about the new head of the Texas Workers' Compensation Program, results of the latest survey by The Physicians Foundation, improvements in patient safety efforts, a court case that upholds a statute for lawsuits involving minors, and potential renewal of the 1115 Medicaid waiver.

Click 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 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.    

CMS Medicare Beneficiary Open Enrollment Ends

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.  

On-Demand Webinars

Prompt Pay and the Revenue Cycle
How to Talk to Patients About Tobacco Cessation
10 Ways to Turn Satisfied Patients Into Loyal Patients
Avoiding the Courthouse: 10 Practice Pitfalls

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Last Updated On

December 20, 2016