Rural Texas Physician

Spring 2016

Rural Texas Physician is a quarterly electronic newsletter catering to physicians in the many rural areas of Texas caring for patients and their communities. TMA’s grassroots membership is the strength of the association. For general inquiries or newsletter comments, email rural@texmed.org.

Act Now to Avoid Losing Your Medicaid Enrollment Status

Thanks to lobbying from TMA and organized medicine, the Centers for Medicare & Medicaid Services extended the deadline for physicians and other health professionals, including advanced practice nurses and physician assistants, to reenroll in Medicaid to Sept. 25, 2016. The initial deadline for reenrollment, driven by a provision in the Affordable Care Act (ACA), was March 24.  

According to the Texas Health and Human Services Commission (HHSC), all physicians participating in Medicaid who have not met all ACA revalidation requirements must do so through reenrollment by Sept. 24, 2016. To avoid disenrollment and possible claims payment disruption, Texas Medicaid officials urge physicians to submit a reenrollment application before June 17, 2016.   

The reenrollment requirement applies to physicians and other health professionals who participate in Medicaid managed care, traditional fee-for-service Medicaid (each active Texas Provider Identifier suffix), the Texas Vendor Drug Program, and long-term care services administered through the Texas Department of Aging and Disability Services.  

If an application has deficiencies but is submitted by June 17, HHSC says there will not be gaps in payment after Sept. 24, if the physician makes a good faith effort to resolve application errors. Applications submitted after June 17 will be processed, but HHSC cannot guarantee those applications will be completed by Sept. 24, which could result in physician disenrollment from Texas Medicaid and denial of payment.

TMA and Texas Medicaid officials encourage Texas physicians to get ahead of the complex reenrollment process.

More Information

Acute Care Physicians Reenrolling Through Texas Medicaid and Healthcare Partnership  

 Ordering- and Referring-Only Physicians

Ordering- and referring-only physicians are those whose only relationship with Texas Medicaid involves ordering or referring services for Medicaid clients. They must enroll with Texas Medicaid as participating physicians.   

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 Texas Medicaid Improves Access to LARCs

Texas Medicaid now allows women to obtain intrauterine devices or implantable contraceptives, collectively known as long-acting reversible contraceptives (LARCs), immediately postpartum. For the past two years, TMA and other physician specialty societies have advocated strongly for the change as a means to increase women's access to the most effective forms of contraceptives.  

Studies show rates of unintended pregnancies drop as women’s access to LARCs increases. Under the new payment policy, hospitals will bill Texas Medicaid or the patient’s HMO for the device, while physicians will bill for the insertion. For further details about the billing changes, visit the Texas Medicaid and Healthcare Partnership website, or consult individual Medicaid HMO provider manuals. 

Women who opt not to obtain a LARC immediately postpartum, but who subsequently seek this form of contraception, can obtain a LARC during the Medicaid 60-day postpartum period. The Texas Women’s Health Program (TWHP) provides coverage for LARCs. Beginning in July 2016, Texas Medicaid will automatically enroll into TWHP those women aged 18 to 44 who lose pregnancy-related Medicaid coverage. The change, which will coincide with renaming TWHP the Healthy Texas Women program, is another TMA-backed measure designed to improve women’s health care. For more information, read “Playing Catch-Up” in the April 2016 issue of Texas Medicine

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 TMA’s Plan Preserves Physicians’ Billing Rights  

The TMA Board of Trustees has approved and sent to the TMA House of Delegates a plan to preserve physicians’ right to bill for their services. Quite a few other states, some members of Congress, and the Obama administration have enacted or proposed legislation that would severely limit or prohibit physicians from billing patients for services provided out of network. The board-appointed Task Force on Balance Billing, which included hospital-based physicians and representatives of several other specialties, devised the plan.  

Board member Keith Bourgeois, MD, a Houston ophthalmologist, chaired the group. Striving to “align [physicians] with the best interests of our patients” and “address the behaviors of insurers that finance health care and apply to all practitioners involved in patient care,” the report recommends:    

  • That TMA “ardently pursue legislative goals” in existing policy designed to “hold insurers accountable for their actions”;

  • Extending mediation for out-of-network billing disputes to patients at all facilities — for all practitioners and all facilities — while maintaining the $500 threshold for mediation;

  • “Mandatory increased state agency oversight of insurers that are often brought to mediation”;

  • For planned surgical procedures or labor and delivery, “development of a standard form for physicians to disclose to patients the identity of other physicians or nonphysician practitioners typically utilized in the facility”; and

  • Continued monitoring of current and proposed laws that rely on large billing databases to set benchmarks or billing standards.   

TMA expects Texas insurance companies and their allies to push a balance billing ban in the 2017 legislative session. TMA’s plan involves extensive public and patient education on insurance industry tactics — narrow networks and arbitrary “maximum allowables” — that increase the likelihood of patients needing services out of network and push more charges onto the patients. 

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Medicaid Restores Payment Levels for Child Vision Services

Medicaid is restoring physician payments for 50 pediatric eye codes to higher levels paid prior to July 1, 2015. The increase, which took effect April 1, averages 6.6 percent across all codes. 

For a comparison of rates, see this chart. Several Medicaid HMOs declined to enact the cuts. For HMO payment rates, refer to each plan’s fee schedule. 

For the past nine months, TMA and the Texas Ophthalmological Association (TOA) advocated strongly to restore the payments, meeting with senior officials from Texas Medicaid to urge a special hearing to review the impact of the lower payments on access to care for children. Anecdotal data collected from TMA and TOA indicated the lower payments had a swift and profound negative impact on low-income children’s ability to obtain timely vision services. The lower payments resulted in many ophthalmologists making the painful decision to limit or discontinue Medicaid participation. At least one physician practice along the border laid off staff and closed its Saturday clinic to make up for the cuts.  

Medicaid implemented the reduction under a routine review of Current Procedural Terminology (CPT) ophthalmology codes and CPT codes for a dozen other physician services. Medicaid rules require all CPT codes to be reviewed at least once every two years. Reviews can result in decreases, increases, or no change in physician payment. 

The pay cuts enacted last year also apply to physician vision services for adult patients. The higher payments taking effect on April 1, however, apply only to children’s services. TMA and TOA will continue to vigorously campaign to restore payments for adult services, too. 

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New Mexico Law Protects Patients’ Access to Care in Texas

Texas doctors will continue to receive a full range of liability protections even when treating New Mexico patients. That issue was in doubt until the New Mexico Legislature took decisive action Feb. 17. 

The legislation preserves vital access to Texas physicians and hospitals for residents of Eastern New Mexico who routinely cross the state line for care. The Texas Alliance For Patient Access (TAPA) says the New Mexico Legislature recognized access to health care is a public policy priority. Without legislation, thousands of patients would lose ready access to primary and specialized care, said Howard Marcus, MD, TAPA chair. 

Under the legislation, the medical liability laws of the state in which a patient received care now will govern cases involving New Mexicans seeking medical care across state lines, provided the patient signs a written consent before receiving treatment. The House and Senate passed the bill unanimously. Gov. Susana Martinez will signed the measure into law on March 3. 

The new law is good news for Texas because the state’s doctors and hospitals have expressed a reluctance to treat visiting New Mexico patients. That followed a New Mexico court ruling that questioned where and under which state laws a suit can be filed if an alleged medical mishap occurs. That case, Montano v. Frezza, is pending before the New Mexico Supreme Court. (Read “Border Battle” in the November 2015 issue of Texas Medicine.)  

For Texas doctors, this meant accepting increased liability risk and costs when treating New Mexico patients. Consequently, many Texas doctors and hospitals were reconsidering their willingness to accept the transfer or referral of a New Mexico patient for elective care. 

The New Mexico law has big implications for access to care in the state. According to the American Medical Association, the Eastern New Mexico counties of De Baca, Guadalupe, Harding, Quay, Roosevelt, and Union have no cardiologist; no neurologist; no plastic surgeon; no orthopedic surgeon; no radiologist; and no ear, nose, and throat doctor. Of those counties, only Roosevelt County has an oncologist. 

Recent data from the New Mexico and Texas departments of health show 13 counties in Southern and Eastern New Mexico send more than 22 percent of their hospitalized patients to Texas for care. 

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Join Your Colleagues in Dallas for TexMed 2016

TexMed 2016, TMA's annual meeting, is just around the corner. Join us April 29–30 at the Hilton Anatole in Dallas, where we will explore Bridging the Gaps. Physician leaders of different specialties from across the state come to TexMed to learn, network, and shape the future of Texas medicine.  

At TexMed you can choose from more than 80 hours of free CME programming. Topics include everything from business operations and the future of medicine to quality initiatives and performance improvement. 

Conference attendees also can help mold TMA policy and business decisions by heading to the House of Delegates and participating in reference committee meetings. All TMA members can testify at the reference committees on resolutions presented before the house.  

And the EXPO provides a great way to see the newest in medical devices, technology, and practice services. Sign up for a free, 15-minute Quick Consult at the TMA Member Services booth #263 and meet face-to-face with TMA staff experts to ask specific questions on various topics, or to address your general practice needs. 

TexMed is a free member benefit, but it’s not just for physicians. Your practice manager and front office staff can benefit from attending TexMed 2016, too. Register today, or check out the Advance Program for more information.  

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Texas Primary Care and Health Home Summit Is June 9–10

Presented by the Texas Medical Home Initiative and Texas Health Institute and cosponsored by TMA, the Texas Primary Care and Health Home Summit will appeal to practices interested in learning about new models of primary care. It will include sessions on successful models in pediatric health homes, the Medicaid 1115 waivers, direct primary care, and value-based care. The summit, which will take place at the JW Marriott Houston Galleria, also will focus on integration of behavioral health into the heath home. 

For more information, visit the summit website

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