Action: Dec. 15, 2015

TMA Action Dec. 15, 2015   News and Insights from Texas Medical Association

Medicare Bonuses for Primary Care Expire Dec. 31
TMA Says Chiropractors Can't Perform Acupuncture
TMA: CMS Needs to Back Off on Medicare Penalties
TMA, AMA Want to Lift Ban on New Physician-Owned Hospitals
TMA Weighs in on Proposed TMB Rules
Meaningful Use Portal Open Jan. 4-Feb. 29 for Attestation
Changes Coming to Newborn Screening Kits Return Policy
Renew Your TMA Dues Automatically; Write Off Expense
TMA Accountable Care Leadership Program Enrolling for 2016
Learn More About TMF's Behavioral Health Network
This Month in Texas Medicine

Medicare Bonuses for Primary Care Expire Dec. 31

Primary care doctors who see a high volume of Medicare patients need to brace themselves for a pay cut starting Jan. 1, 2016. A provision in the Affordable Care Act that provided Medicare payment bonuses to primary care physicians is expiring on Dec. 31. That means some Texas physicians will lose hundreds of thousands of dollars with the extinction of the Centers for Medicare & Medicaid Services (CMS) Primary Care Incentive Payment Program (PCIP), which aimed to narrow the gap in Medicare payments between primary care physicians and specialists.

To receive the quarterly incentive payments, which began in 2011, physicians' primary care services (CPT codes 99201 through 99215 and 99304 through 99350) had to account for at least 60 percent of their total allowed charges under the physician fee schedule in the calendar year. Eligible physicians include those with a Medicare specialty designation of family medicine, geriatrics, pediatrics, and internal medicine.

According to CMS, incentive payments are equal to 10 percent of the Medicare paid amount for primary care services. In 2012, the most recent year of available data, Medicare paid more than $664 million to about 170,000 eligible PCIP practitioners, who each received an average of $3,938, per a report last year by the Medicare Payment Advisory Commission. CMS reports health professionals, including nurse practitioners, physician assistants, and clinical nurse specialists, practicing in urban and rural areas of Texas received PCIP payments totaling $43.6 million in 2012.

One family physician who contacted TMA, said his 13-physician practice expects to lose $100,000 in Medicare payments next year due to the elimination of PCIP.

Medicare Payment for Doctors Not Looking Good in 2016

The Medicare Access and CHIP Reauthorization Act (MACRA), also known as the "doc-fix" bill, completely eliminated the old Sustainable Growth Rate (SGR) budgetary formula that threatened us with large fee cuts every January for the past 15 years. That's the good news. The bad news is: 

  • The new required fee updates are not adequate to cover increasing costs; and;
  • While we were scrambling every year to convince Congress to appropriate some money to avoid those steep SGR cuts, we accepted some provisions in those temporary doc-fix bills that are now coming back to bite us.

One of those provisions from a 2014 bill is now causing a fee cut instead of the small increase that MACRA required for Jan. 1, 2016. Instead of the MACRA-required fee update of one-half of 1 percent, physicians will get a cut of about half that size. The 2016 conversion factor will be $35.8279, down from $35.9335 in 2015. This produces a cut of about 20 cents in the fee for a midlevel office visit (code 99213).

Overall, Medicare fees are not improving, and compliance to avoid penalties is adding cost for physicians. Further congressional action will be required to improve the situation.  

Other factors affecting 2016 fees are: 

  • The extension of the work geographic practice cost index (GPCI) until 2017, raising fees by a few percent in three Texas payment localities.
  • Various relative value unit (RVU) fee revisions.
  • Expiration of the 10-percent primary care bonus, effective Jan. 1, 2016.
  • Possible effect of the value-based payment modifier on practices with 10 or more eligible providers.
  • Possible application of meaningful use and Physician Quality Reporting System penalties, even for nonparticipating physicians.
  • The continuation of the 2-percent sequestration.   

TMA Says Chiropractors Can't Perform Acupuncture

TMA told the Third District Court of Appeals that the Texas Board of Chiropractic Examiners went too far in allowing chiropractors to perform acupuncture. TMA filed an amicus curiae brief with the court asking for a reversal of the trial court's judgment in Texas Association of Acupuncture and Oriental Medicine v. Texas Board of Chiropractic Examiners and Yvette Yarbrough. Doing so would invalidate the chiropractic board's controversial rule. 

In the brief, TMA says the chiropractic board's rules on acupuncture exceed what state law allows under the Chiropractic Act. The association also points out the Chiropractic Act doesn't authorize any procedures on the nervous system nor does it authorize chiropractors to perform acupuncture.

TMA's brief states the Chiropractic Act "addresses biomechanical conditions of the musculoskeletal system, not acupuncture." 

Previously, the Texas Association of Acupuncture and Oriental Medicine (TAAOM) filed a lawsuit requesting invalidation of the chiropractic board's rules. The trial court sided with the chiropractic board and denied TAAOM motion for summary judgment. The acupuncture association appealed the trial court's judgment. 

The appeal hearing took place on Dec. 2. At the hearing, the chiropractic board's counsel contended that because the Chiropractic Act prohibits only the performance of incisive procedures, chiropractors should be able to perform acupuncture within the scope of their practice act. There was some discussion of whether biomechanics encompassed the use of acupuncture, with one justice saying, "Acupuncture is about nerves; that's different from biomechanics." A decision is expected next year.

TMA: CMS Needs to Back Off on Medicare Penalties

An error on the part of the Centers for Medicare & Medicaid Services (CMS) penalizes some physicians, forcing those affected by the blunder to appeal a potential payment cut by Dec. 16. Last month, the agency announced it had "issues" with data submitted by physicians who participated in the CMS Physician Quality Reporting System (PQRS) and value-based payment modifier (VBM) programs. CMS also had "issues" with how it used that data to calculate payment penalties. The hassle caused by CMS means those physicians who took part in PQRS and VBM have to dust off their quality and cost reports to determine whether they're among the thousands at risk of incurring payment penalties come Jan. 1, 2016. 

TMA President Tom Garcia, MD, told Congress in a letter on behalf of TMA that CMS' "'issues' meant that thousands of U.S. physicians will now see their Medicare payments cut by 2 to 4 percent next year." And in the midst of the appeal process, known as the informal review period, CMS has provided "conflicting and confusing information about its quality and cost reports and the appeals process."

Along with the American Medical Association, TMA wants Congress "to tell CMS to back off on penalizing physicians who in good faith participated in PQRS in 2014." At the very least, medicine is requesting an extension to the appeals deadline into next year to allow physicians sufficient time to review their reports and understand whether they should file an appeal. 

"Our experience of just the past few months has proven that CMS is much better at generating mass confusion than it is at helping physicians care for Medicare and Medicaid patients," Dr. Garcia wrote. "The agency's incompetence only multiplies the burden of numerous, overly complex regulations it forces onto physicians."   

If you submitted data to PQRS for the 2014 reporting period, you really need to review your quality and cost reports. CMS uses the data in these reports to calculate your quality and cost performance scores, determining how you'll get paid under the 2016 Medicare Part B Physician Fee Schedule. According to an AMA news alert, "problems with how CMS has been collecting and analyzing data related to the PQRS and VBM programs are leading to inappropriate penalties of 2-4 percent of Medicare payments for thousands of physicians."

On Sept. 9, CMS announced the release of two reports: the 2014 PQRS feedback report and the quality and resource use report (QRUR) under the VBM program. On Nov. 16, CMS released revised reports due to initial "issues with data submitted to PQRS by electronic health records and qualified clinical data registries, and technical issues related to claims used to calculate claims-based measures." This recalculation process resulted in lower performance scores for many physicians, and now more physicians than ever will receive payment penalties in 2016. Read more on this matter and other problems related to the reports in the AMA letter to CMS (letter available to AMA members only).

Reports and Appeals Process

If you haven't seen your reports, review them now. If you’ve already reviewed your reports, check again for new and revised versions. If Medicare says you'll receive the 2016 payment cut, or if you're confused or concerned about receiving a penalty, file an appeal, known as an "informal review request," by Dec. 16 for each report you want to contest. This is the only appeals process Medicare has for the PQRS and VBM programs and the only opportunity you'll have to appeal your penalties before the pay cuts take effect on Jan. 1, 2016.

Follow these steps to access your reports and file an appeal: 

Help for You From TMA

TMA is collaborating with TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) to connect TMA members to free services to help them navigate Medicare requirements to avoid penalties and maximize value-based payments. TMF QIN-QIO provides no-cost consulting services and technical assistance to solo physicians, group practices, and other health care professionals for Medicare's quality programs. 

For help with your reports or the informal review process, contact Tracy Swoboda at TMF QIN-QIO by phone at (361) 258-1053 or email. And join the TMF Value-Based Improvement and Outcomes Network to take advantage of free services. Learn more about TMF QIN-QIO in the December issue of Texas Medicine

For questions about PQRS feedback reports and guidance on the PQRS informal review process, contact the CMS Quality Net Help Desk at (866) 288-8912 Monday through Friday, 7 am-7 pm CT (select option 3, then 7), or by email.

For questions about QRURs and guidance on the VBM informal review process, contact the CMS Physician Value Help Desk at (888) 734-6433 Monday through Friday, 7 am-7 pm CT (select option 3), or by email.

Visit TMA's PQRS Resource Center for more on how to participate in the PQRS and VBM programs.    

Action TMLT Ad 10.15

TMA, AMA Want to Lift Ban on New Physician-Owned Hospitals

TMA and the American Medical Association aren't too thrilled with legal limitations placed on the expansion of physician-owned hospitals. The organizations told Congress just that in a letter of support for HR 2513, legislation introduced by Reps. Sam Johnson (R-Texas) and Ruben Hinojosa (D-Texas) that would partially lift the ban on new physician-owned hospitals and also address limitations on the growth of existing facilities. 

The Congressional Research Service's summary of the bill indicates the Promoting Access, Competition, and Equity Act of 2015, or PACE Act, amends Medicare "to ease application criteria and procedures for physician-owned hospitals to expand their facilities. Under current law, expansion of physician-owned hospitals is subject to certain limitations, such as those regarding the extent and frequency of expansion and requiring community output. The bill suspends these limitations with respect to applications for expansion filed before October 1, 2019."

The bill also "exempts physician-owned hospitals from specified documentation and coding adjustments, and extends reductions in certain inflationary increases associated with Medicare payments for inpatient hospital services."

In the letter, TMA, AMA, and 40 other medical societies and organizations say they oppose the provision in the Affordable Care Act that "strictly prohibits any new physician-owned hospitals from participating in Medicare and Medicaid." The organizations add that provision of ACA creates an "unlevel playing field in the health care system for one particular model of hospital ownership."

"The inability of physician-owned hospitals to address the growing demand for high quality health care services in their community is bad for our entire health care system and does nothing but penalize patients who should have the right to receive care at the hospital of their choice," the letter states. 

TMA Weighs in on Proposed TMB Rules

TMA has been busy submitting comments on proposed Texas Medical Board (TMB) rules. TMA President Tom Garcia, MD, signed three separate comment letters, which pertain to out-of-network claim dispute resolution; a monitoring, proctoring, or supervising physician/professional's recommendation for competency assessment; and visiting physician temporary permits.

TMB is in the process of updating its rules to reflect the changes in state law made by Senate Bill 481 by Sen. Kelly Hancock (R-North Richland Hills). The bill lowers the threshold for patients to initiate mediation for certain claims for services provided by out-of-network, facility-based physicians at in-network hospitals from $1,000 to $500 (after copayments, deductibles, and coinsurance). As initially proposed, the bill would have eliminated the threshold altogether, which TMA successfully fought to change. 

Additionally, the bill, as passed, amended the definition of "facility-based physicians" to include assistant surgeons. The bill also required that billing statements contain a "conspicuous, plain-language explanation" of the mandatory mediation process (when available).

In its comments, TMA contends the scope of the rules is broadened inappropriately by the current definition of "facility" in TMB rules. The board rules define a facility as a "hospital, emergency clinic, outpatient clinic, birthing center, ambulatory surgical center, or other facility providing health care services." TMA says the definition "goes far beyond hospitals (i.e., the only type of 'facility' to which the mediation process established under Chapter 1467, Insurance Code actually applies)."

TMA concludes by stating "that utilizing a definition of 'facility' … that extends beyond hospitals would be problematic for physicians and patients, alike. Since all the provisions in Subchapter J, Chapter 187 of the Board rules relate to the mediation process established under Chapter 1467 of the Insurance Code, the definition of 'facility' in the 22 TAC §187.87 needs to accurately reflect the circumstances when mediation is available under that law (i.e., for certain claims for services provided by certain out-of-network hospital-based physicians at in-network hospitals). To do otherwise would lead to physician confusion regarding the mandates of the law and patient confusion regarding the circumstances when mediation is available."

At its Dec. 4 meeting, TMB voted to adopt the rule as published but directed staff to research some of the issues raised in TMA's letter ahead of the next TMB meeting in March.

Competency Assessment Rules

In TMA's comments on TMB's proposed rule concerning a monitoring, proctoring, or supervising physician/professional's recommendation for competency assessment, the association says the rule "does not go far enough in terms of what must happen before a physician is subject to a competency evaluation." In the comments, Dr. Garcia describes competency hearings as "costly," adding they "interfere with the operations of a physician's medical practice and can be embarrassing and stigmatizing for a physician's reputation."

"While TMA acknowledges that competency evaluations may play a role in protecting the public health and welfare, TMA strongly opposes the imposition of competency evaluations without appropriate due process," Dr. Garcia wrote.

TMA says TMB's informal settlement conference (ISC) provides an appropriate mechanism for determining whether a competency evaluation is necessary. Holding an ISC prior to ordering a competency evaluation, TMA explains, would allow the monitor and the doctor "to present evidence and allow the panel to make an informed determination of whether a competency evaluation is warranted."

At its Dec. 4 meeting, TMB voted to adopt the rule as published, with the understanding that physicians be able to respond in writing to the Disciplinary Process and Review Committee chair regarding any recommendation by a monitor that a competency exam be ordered. TMA requested this in its comment letter.

Temporary Permit Rules

TMA also weighed in on proposed TMB rules concerning visiting physician temporary permits. The proposed rules would prohibit a supervising physician from having "an investigation or proceeding pending against the applicant for the restriction, cancellation, suspension, revocation, or other discipline of the applicant's medical license, permit, or authority to practice medicine." TMA recommends the term "applicant" be changed to "supervising physician" in the rules.

TMA says visiting physicians with a temporary permit should be able to be supervised by any physician with an unrestricted Texas license. "TMA believes that this new proposal, if adopted, would prevent many competent physicians from acting in a supervisory capacity," Dr. Garcia wrote. "TMA recommends that proposed sections 172.5(a)(2)(C)(ii) and 172.5(b)(1)(B)(ii) be deleted."

At its Dec. 4 meeting, TMB adopted the changes to the rules as published but with TMA's suggestion to change "applicant" to "supervising physician." 

Meaningful Use Portal Open Jan. 4-Feb. 29 for Attestation

The Centers for Medicare & Medicaid Services (CMS) is updating the meaningful use attestation portal to align with the modified Stage 2 measures released on Oct. 16, 2015. The portal will be open for 2015 program year attestations from Jan. 4 to Feb. 29, 2016. 

Use these CMS resources to learn about the program requirements in depth and prepare for attestation: 

If you were unable to plan for the 2015 reporting period due to the very late publication of the 2015-17 modification final rule, you may apply for a hardship exception under the "extreme and uncontrollable" circumstances category. The hardship exception may apply to a small number of physicians because the modifications reduced the number of measures and some of the percentage requirements. In the event of a potential audit, it's important to keep documentation of the specific circumstances that prevented you from meeting the modified version of meaningful use.

Hardship applications will be available in early 2016 on the CMS website. If you have questions, contact the TMA Health Information Technology helpline at (800) 880-5720, or email hit[at]texmed[dot]org. Texas' regional extension centers also can help physicians achieve meaningful use.  

TMAIT Action Ad 6.15

Changes Coming to Newborn Screening Kits Return Policy

Starting Jan. 1, 2016, the Texas Department of State Health Services (DSHS) will issue a refund or credit for returned newborn screening specimen collection kits only if the kit is thought to be defective. 

The Texas Administrative Code states that "if the purchaser believes a kit(s) is defective, purchaser should immediately contact the department's laboratory in Austin. Kit(s) which are verified to be defective by the department can be returned for credit for future kit orders, as directed by the department." DSHS says credits toward future kit purchases will not be allowed for any other reason.

Renew Your TMA Dues Automatically; Write Off Expense

Do you have funds remaining in your 2015 continuing medical education or dues budget allotment? If so, you can renew your 2016 TMA membership now, before your funds expire. TMA estimates 83 percent of your membership dues may be deductible as ordinary and necessary business expenses.

Don't forget to select the "Automatic Dues Renewal" option. TMA can securely keep your credit card number on file and renew your TMA membership automatically each year, ensuring continued access to the many benefits and services and solutions for your practice headaches. Enroll today, get the TMA publication Business Basics for Physicians free of charge, and you'll never worry about your benefits lapsing.

Thanks in advance for helping TMA use your membership dollars for purposes more worthwhile than shuffling paper.

To enroll or to get all your practice and renewal questions answered, call the TMA Knowledge Center at (800) 880-7955 or login to your member profile on the TMA website

TMA Accountable Care Leadership Program Enrolling for 2016

Are you ready to learn more about the new health care landscape? TMA is now accepting applications for the 2016 Accountable Care Leadership Program. Applications are due Jan. 15. To view the sample curriculum, get more information, or apply, see the TMA website. 

The program, which graduated its inaugural class in November, helps ensure physicians are leading the charge in health care transformation. TMA launched the program hand in hand with TMA PracticeEdge, a physician services organization designed to support physicians in taking advantage of new payment models. 

Participants in the 10-month certificate program learn topics like communication skills, teamwork, and population health management, meant to help physicians adapt in a rapidly changing environment that demands more accountability and proof of value for the health care dollar. Physicians can access lectures, readings, quizzes, and case studies 24/7, putting in an estimated 10 hours of homework every three weeks. Participants also take part in two in-person TMA-hosted sessions — a program kickoff and a capstone to conclude the program. 

The curriculum, developed and administered by the University of Texas at Dallas, imparts practical skills relevant to all specialties. Upon completion, physicians earn a certificate from UT Dallas and continuing medical education credits from the American Medical Association and TMA. 

PC Action Ad Oct 13

Learn More About TMF's Behavioral Health Network

The TMF Quality Innovation Network Quality Improvement Organization's (QIN-QIO's) new Behavioral Health Network offers tools and training to help increase screening rates for Medicare beneficiaries receiving care at primary care practices. With depression screenings and annual behavioral assessments now routinely covered under the Affordable Care Act, primary care physicians will be paid adequately for these essential preventive services.

Network participants receive access to free resources and training to help increase screening rates for depression and alcohol use disorders. The network also aims to reduce the 30-day readmission rate and increase follow-up care for patients discharged from inpatient psychiatric facilities. 

The Behavioral Health Network is just one of three physician-focused programs recently established by TMF QIN-QIO to help you save time, improve patient care, and reduce costs associated with meeting certain Centers for Medicare & Medicaid Services' requirements. The other networks, which focus on immunizations and value-based improvements such as Medicare's Physician Quality Reporting System and value-based payment modifier program, help physicians benefit from — and not be penalized by — Medicare mandates.

For more information on participating in the behavioral health network, visit the TMF QIN-QIO website, or download and complete the network participation agreement

This Month in Texas Medicine

The December issue of Texas Medicine features a cover story on the proposed Aetna-Humana merger, which TMA and physicians across Texas say will result in less competition in the marketplace and higher health insurance premiums. In the issue, you'll also find information on the impact social media has had on marketing a physician practice, TMF Health Quality Institute resources that will better position doctors for the rapid transition to value-based payment, the need for an update to Texas law that would give physicians the power to hold dangerous patients for a finite length of time, and the move to virtual credit cards by some health plans and third-party vendors that process plan payments.

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.

Dec. 16, 2015 
Last Day to Appeal Errors in Your PQRS Feedback Report and QRUR  

Jan. 1, 2016
EHR Incentive Program's First Day of the 2016 Reporting Period

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 Webinar

New Initiatives for Texas Medicaid Providers


Texas Health Steps programs — Free CME! 
Use coupon code THSEDU for free registration. 


Electronic Medical Records Implementation: Successful Strategies from the Front Lines  

Overcoming Barriers to Medical Home Implementation  

Conferences and Events

2016 TMA Winter Conference
Jan. 29-30
Hyatt Regency Austin

About Action       

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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, Action editor. 

Last Updated On

September 26, 2018