News

MGMA SHARES MEDICARE PAYMENT REFORM RECOMMENDATIONS WITH CONGRESS

MGMA submitted a letter for the record to the House Committee on Energy and Commerce Subcommittee on Oversight and Investigations ahead of their hearing, “MACRA Checkup: Assessing Implementation and Challenges that Remain for Patients and Doctors.” The Subcommittee examined the Quality Payment Program (QPP) that was instituted under the Medicare Access and CHIP Reauthorizations Act of 2015 (MACRA) and discussed challenges practices face related to the legislation.

Our comments included recommendations on how to reform the program such as providing an annual inflationary-based physician payment update based on the Medicare Economic Index (MEI), providing positive financial incentives to support practices transitioning to value-based care, and opposing efforts to offset unrelated congressional spending to the detriment of Medicare providers. MGMA expects Congress to continue reviewing potential options for MACRA reform in the coming months and we will engage with policymakers to advocate for solutions that provide for sustainable reimbursement to medical groups.

MGMA ADVOCATES FOR BEHAVIORAL TELEHEALTH CARE

The House Committee on Energy and Commerce Subcommittee on Health held a hearing on the reauthorization of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT) for Patients and Communities Act. The Subcommittee discussed numerous provisions of the SUPPORT Act with witnesses from several federal agencies tasked with enforcing the law.

MGMA sent a letter recommending policies to the Subcommittee that would support medical groups’ ability to offer high-quality mental health and behavioral telehealth care. The letter advocated for instituting an appropriate process for the administration of controlled substances via telehealth and to remove the in-person requirement for behavioral telehealth visits.

JOIN MGMA FOR OUR MID-YEAR POLICY UPDATE WEBINAR

Join MGMA Government Affairs staff for our member-exclusive, mid-year policy update to review current federal policies and their impact on group practices. Attendees will learn about the congressional and regulatory landscape as it pertains to medical practices, federal payment issues on the horizon, and the latest on MGMA's advocacy and member engagement. There will be time for Q&A at the end of the presentation, so come ready with your questions!

This webinar will be held on July 18, 2023, at 1 p.m. ET and will eligible for ACMPE, ACHE (live only), CME (live only), CPE (live only), PDC (live only), PDU (live only) and CEU credit. Register for the webinar here. 

CMS ANNOUNCES NEW PRIMARY CARE MODEL

Last week, the Centers for Medicare and Medicaid Services (CMS) announced the launch of a new voluntary model focused on primary care, the Making Care Primary (MCP) Model. This 10.5-year model will launch on July 1, 2024, and be tested in eight states. CMS intends for the MCP Model to strengthen the primary care infrastructure in the county while focusing on safety net and smaller or independent primary care organizations.

There will be three participation tracks that build on previous primary care models and provide a pathway for primary care clinicians to adopt prospective, population-based payments. CMS is working with state Medicaid agencies in the eight participating states and plans to engage with private payers in the coming months to engage in full care transformation across payers. The application will open in late summer 2023 for primary care organizations within the participating states.

CMS RELEASES 2021 QUALITY PAYMENT PROGRAM EXPERIENCE REPORT

On Monday, CMS released its 2021 Quality Payment Program (QPP) Experience Report, an infographic, and a Public Use File (PUF) to provide insights into QPP participation. The report and infographic review performance and participation data for the MIPS and Advanced Alternative Payment Models (APMs) performance tracks, while the PUF provides individual clinicians who received a 2021 MIPS final score with detailed information.

The mean final score for MIPS eligible clinicians participating as individuals rose from 64.66 in 2020 to 71.61 in 2021, and the number of Qualifying Advanced Model Participants (QPs) rose from 235,225 in 2020 to 271,231 in 2021. See the 2021 QPP Experience Report for more key findings and to review elements important to the QPP.

“CURRENT LANDSCAPE OF HEALTHCARE ON THE HILL" MGMA SUMMIT SESSION ON-DEMAND

Did you miss our “Current Landscape of Healthcare on the Hill” virtual session at the MGMA Summit? It's now available to attendees on-demand! Director of Government Affairs Claire Ernst was joined by President & CEO of Medical Revenue Cycle Specialists Kem Tolliver for an interactive discussion on the latest developments in Washington, D.C. impacting medical group practices. View the recording today to get an inside look at Congress’ priorities pertaining to physician practices, as well as the steps the Administration is taking to address key issues.

Use your Summit credentials to log in and search “Current Landscape of Healthcare on the Hill” to find the session!

CMS WITHDRAWS COVID-19 HEALTHCARE FACILITY VACCINATION REQUIREMENTS

Yesterday evening, the Centers for Medicare & Medicaid Services (CMS) issued a rule which, in part, withdraws the COVID-19 healthcare staff vaccination requirements established in a November 2021 interim final rule. The November 2021 rule required most Medicare- and Medicaid-certified providers and suppliers to ensure COVID-19 vaccination of staff. This rule largely did not apply to physician offices. Although CMS is withdrawing the staff vaccination provisions, the agency intends to encourage ongoing COVID-19 vaccination through its quality reporting and value-based incentive programs.

MGMA SUBMITS TESTIMONY TO HOUSE COMMITTEE ON WAYS & MEANS SURROUNDING NO SURPRISES ACT

MGMA submitted testimony earlier this week to the House Committee on Ways and Means in response to its May 16 hearing, “Health Care Price Transparency: A Patient’s Right to Know.” The testimony centers on the No Surprises Act (NSA) and concerns about the way certain provisions may be implemented due to current limitations in the healthcare environment and available infrastructure.

While supporting the underlying goals of the transparency provisions of the NSA, MGMA raised concerns about increasing administrative burden for practices without increasing transparency regarding the Advanced Explanation of Benefits (AEOB) and convening/co-provider requirements. Specifically, MGMA highlighted the need for a uniform and automated standard to be available before the requirements go into effect. Policymakers must work with medical groups to institute polices that empower patients without impacting the delivery of care.

HOUSE PASSES DEBT CEILING BILL  — A STEP CLOSER TO AVOIDING DEFAULT

On May 31, the House of Representatives voted to pass H.R. 3746 — the Fiscal Responsibility Act of 2023 — averting U.S. default on the debt limit and enabling continued Medicare and Medicaid payments. This politically fraught legislation includes a two-year debt ceiling suspension, discretionary spending caps, expanded work requirements for SNAP and TANF, and cuts to IRS funding. The Congressional Budget Office estimates the legislation will result in cuts to the federal deficit by $1.5 trillion over the next decade. The bill is now headed to the Senate — if the full Congress does not pass the bill by the Monday deadline, the U.S. could risk a default on the nation's debt. MGMA Government Affairs will continue to monitor and provide updates to membership. 

POTENTIAL IMPLICATIONS OF DEBT CEILING DEBATE FOR MEDICAL GROUPS

On May 15, the United States Department of Treasury notified Congress that it would not be able to finance the government's obligations as early as June 1 if legislators do not raise or suspend the $34.1 trillion debt limit. The Administration and Congress are continuing to negotiate to prevent the federal government from defaulting on its agreements. Given the unprecedented nature of a default, it is unclear what federal payments will be prioritized although medical group practices could see delays or cuts to Medicare and Medicaid reimbursements within a few days of default. 

As we approach the estimated default date, MGMA Government Affairs will continue to provide timely information on the implications of default to medical group practices. 

CMS UPDATES TELEHEALTH GUIDANCE FOR VARIOUS SERVICES IN FACILITY-BASED SETTINGS

The Centers for Medicare & Medicaid Services (CMS) released an updated FAQ on waivers, flexibilities, and the end of the COVID-19 public health emergency (PHE). CMS states in the document that it will exercise enforcement discretion to continue paying for telehealth services offered by physical therapists (PT), occupational therapists (OT), and speech-language pathologists (SLP) in facility-based settings.

The agency updated its position on covering telehealth for PT, OT, and SPT after receiving numerous inquiries from providers and healthcare organizations. Telehealth services are allowed from hospital outpatient departments, rehabilitation agencies, skilled nursing facilities, and home health agencies. Providers should continue to furnish services and bill the same way they have been during the PHE according to the FAQ.

MGMA WRITES CONGRESS IN SUPPORT OF LEGISLATION TO EXPAND PHYSICIAN WORKFORCE

MGMA joined a coalition of nearly 80 healthcare organizations in sending a letter of support to the congressional Senate sponsors of the Resident Physicians Shortage Reduction Act of 2023. This bipartisan bill would create 14,000 additional Medicare-supported Graduate Medical Education (GME) positions over the next seven years. This legislation would help address the projected shortage of up to 124,000 primary care and specialty physicians by 2034, and build upon the 1,200 slots Congress added over the past few years.

Contact your members of Congress today to express your support for expanding the physician workforce.

MGMA SUBMITS COMMENTS TO SENATE SUBCOMMITTEE FOR HEARING ON DENIALS AND DELAYS IN MA

On May 17, the Senate Committee on Homeland Security & Governmental Affairs Permanent Subcommittee on Investigations held a hearing titled, “Examining Health Care Denials and Delays in Medicare Advantage." The hearing’s witnesses included Medicare policy experts, a benefits specialist, and leadership from the Department of Health and Human Services (HHS) Office of Inspector General (OIG). In April 2022, OIG published a report that found some Medicare Advantage (MA) organization denials of prior authorization (PA) limited beneficiaries’ access to medically necessary care.

As part of the MGMA’s efforts to highlight the burden of PA on medical group practices and its negative impacts on patient care, MGMA Government Affairs shared our recent report on the escalating utilization of PA within the MA program and additional written comments outlining our mounting concerns with Subcommittee staff.

"HEALTHCARE ON THE HILL" SESSION AT MGMA SUMMIT

Attending MGMA Summit next month? You won’t want to miss our “Current Landscape of Healthcare on the Hill” virtual session on Thursday, June 8 at 11 a.m. ET. Director of Government Affairs Claire Ernst will be joined by Taya Gordon and Kem Tolliver for an interactive discussion on the latest developments in Washington, D.C. impacting medical group practices. Attendees will get an inside look at Congress’ priorities pertaining to physician practices, as well as the steps the Administration is taking to address key issues. This session will provide updates on Medicare reimbursement, prior authorization reform, surprise billing, and more!

Additional information on MGMA Summit, including registration details and a full schedule of events, may be found here.

MGMA RESOURCES OUTLINGING STATUS OF VARIOUS FLEXIBILITIES AND WAIVERS FOLLOWING PHE

• GovChat Live: Unwinding of the PHE FAQ
• GovChat Live: Unwinding of the PHE (slides & recording)
• Flexibilities & policy following expiration of PHE *Updated May 17, 2023*
• Medicare Telehealth Waivers *Updated May 17, 2023*

NEW MGMA REPORT TARGETS ESCALATING USE OF PRIOR AUTHORIZATION BY MA PLANS

Following substantial growth of enrollment in Medicare Advantage (MA) plans during the previous two decades, in April 2022, the Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) published a report which detailed how MA beneficiaries' care was often negatively impacted as a result of delayed and denied prior authorization requests, despite the requests meeting Medicare coverage rules.

To further understand the critical impact of prior authorization within the MA program, and to allow us to better educate Congress and the Administration about obstacles to delivering high-quality patient care to beneficiaries, in March of 2023, MGMA surveyed over 600 medical groups. Findings overwhelmingly show that prior authorization in MA is increasingly burdensome for medical group practices and contributes to increased practice administration costs, disrupted practice workflow, and dangerous delays and denials of necessary medical care.

• View MGMA's full report
• View MGMA's statement on the findings

CMS ACCEPTING APPLICATIONS FOR '23 MIPS EUC AND PROMOTING INTEROPERABILITY EXCEPTIONS

The Centers for Medicare and Medicaid Services (CMS) opened applications for the Merit-based Incentive Payment System (MIPS) Extreme and Uncontrollable Circumstances (EUC) Exception and the Promoting Interoperability Performance Category Hardship Exception for performance year 2023. The applications will close at 8 p.m. ET on Jan. 2, 2024. For MIPS eligible clinicians, groups, and virtual groups, extreme and uncontrollable circumstances are rare events entirely outside of a clinician’s or group’s control that would:

• Cause you to be unable to collect information necessary to submit for a MIPS performance category;
• Cause you to be unable to submit information that would be used to score a MIPS performance category for an extended period of time (for example, if you were unable to collect data for the quality performance category for 3 months), and/or;

BIDEN ADMINISTRATION ENDING SEVERAL COVID-19 VACCINATION REQUIREMENTS

The Biden administration announced it will end the COVID-19 vaccine requirements for federal employees, federal contractors, and international air travelers at the end of the day on May 11. These vaccination requirements were announced in 2021 and will end on the last day of the COVID-19 public health emergency (PHE).

The Department of Health and Human Services (HHS) also announced on Monday that it will start the process to end vaccination requirements for CMS-certified healthcare facilities and Head Start educators. HHS is expected to release further information in the coming days on the unwinding of its vaccination requirements. As a reminder, this policy is applicable to facilities that participate in/are certified under the Medicare/Medicaid programs and are regulated by Conditions of Participation, Conditions of Coverage, or Requirements for Participation — physician practices were largely outside of the scope.

MGMA COMMENTS ON CMS’ HIPAA ATTACHMENT STANDARDS PROPOSED RULE

Last week, MGMA submitted comments to the Centers for Medicare & Medicaid Services (CMS) in response to its proposed rulemaking to establish Health Insurance Portability and Accountability Act (HIPAA) attachment standards. The proposed rule would establish electronic standards for sending attachments in claims and prior authorization transactions. Attachments are currently transmitted through a primarily manual process, and CMS has been tasked with establishing attachment standards for decades.

MGMA’s comments focused on the need for CMS to ensure the prior authorization attachment standard aligns with all other aspects of the agency’s prior authorization reform efforts, instituting an improved HIPAA attachment standards development process focusing on real-world testing, and implementing a claims attachment standard that works for medical groups. 

MGMA TO CONGRESS: REPEAL THE PATIENT ID PROHIBITION

MGMA joined over 150 other healthcare organizations in a letter asking Congress to repeal Section 510 in the Labor, Health and Human Services, and Education and Related Agencies (Labor-HHS) appropriations bill. A narrow interpretation of the language in Section 510 has prevented progress on a unique patient identifier resulting in numerous negative consequences to patient care and financial burdens to medical groups.

MGMA ENDORSES THE CHRONIC CARE MANAGEMENT IMPROVEMENT ACT OF 2023

MGMA and over two dozen other healthcare stakeholder organizations sent a letter to Congress in support of the Chronic Care Management Improvement Act of 2023. This bipartisan legislation would increase access to chronic care management (CCM) services for Medicare beneficiaries and enable group practices to better manage the chronic conditions of their patients by removing the burdensome cost sharing requirement. Currently, Medicare beneficiaries are subject to a 20% co-insurance requirement for CCM services, increasing the administrative burden on practices by requiring the continuous collection of minimal fees from patients.

Join in #MGMAAdvocacy today by sending a letter to your members of Congress urging them to pass legislation to remove patient cost sharing for CCM services!

MGMA and over two dozen other healthcare stakeholder organizations sent a letter to Congress in support of the Chronic Care Management Improvement Act of 2023. This bipartisan legislation would increase access to chronic care management (CCM) services for Medicare beneficiaries and enable group practices to better manage the chronic conditions of their patients by removing the burdensome cost sharing requirement. Currently, Medicare beneficiaries are subject to a 20% co-insurance requirement for CCM services, increasing the administrative burden on practices by requiring the continuous collection of minimal fees from patients.

PUBLIC HEALTH EMERGENCY: MEMBER QUESTION OF THE WEEK!

n preparation for the end of the declared COVID-19 Public Health Emergency (PHE) on May 11, 2023, MGMA has been tracking frequently asked member questions related to its unwinding. Please see a common member question on this issue below:

Q: Will the U0005 add-on payment for COVID-19 diagnostic testing run on high-throughput tech expire with the end of the PHE?

CMS FINALIZES MA RATE NOTICE - PHASES IN CHANGES 

Last Friday, the Centers for Medicare & Medicaid Services (CMS) released the Announcement of Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies (the Rate Announcement). The Rate Announcement finalized policies like making technical changes to the growth rate estimate, implementing changes to the Part D drug program from the Inflation Reduction Act, and changes to the risk adjustment model.

MGMA advocated to pause the implementation of changes to the risk adjustment model to mitigate any potential unintended consequences impacting beneficiary access to care and value-based care initiatives critical to the success of medical group practices. In response to the concerns of MGMA and other stakeholders, CMS announced that the changes to the risk adjustment model will be phased in over three years rather than all at once. MGMA will continue to monitor the potential impact that these changes will have on group practices.

MEDICARE BOARD OF TRUSTEES RELEASE 2023 REPORT

The Medicare Board of Trustees has released its 2023 report, projecting that the Hospital Insurance Trust Fund would only be able to pay 100% of total scheduled benefits until 2031. The Board had previously estimated that the program would become insolvent three years earlier. The report also outlines projections showing that steep increases in Medicare costs will lead to lower relative reimbursement rates for provider groups. Compounding these concerns, it's also been noted that physicians are slated for payment reductions in future years and that the updates to physician payment in the law do not tie reimbursement to underlying economic conditions like inflation.

MGMA Government Affairs will continue to advocate for policy solutions that will ensure reimbursement rates reflect the true costs of delivering care.

HOUSE SUBCOMMITTEE HOLDS HEARING ON HEALTHCARE TRANSPARENCY AND COMPETITION 

On Tuesday, the House Committee on Energy & Commerce Subcommittee on Health held a hearing on transparency and competition in healthcare. Five panelists testified including the CEO of Pullman Regional Hospital and a Senior Fellow from the American Enterprise Institute.

The majority of the discussion focused on the hospital price transparency rule, the transparency in coverage rule, pharmacy benefit managers, drug pricing policies, and consolidation. Committee members and the panel highlighted potential areas for oversight and legislation such as codifying price transparency policies. MGMA Government Affairs will continue to engage with the Committee on these and other priority issues.

MGMA SUBMITS FEEDBACK TO SENATE HELP COMMITTEE ON HEALTHCARE WORKFORCE SHORTAGES

On Monday, MGMA Government Affairs submitted a letter to the U.S. Senate Committee on Health, Education, Labor, and Pensions (HELP) in response to a request for information (RFI) about how address the healthcare workforce shortage. The letter thanked the Committee for their attention on this pressing issue and offered the following recommendations:

• Physician payment reform: Medicare physician payment continue to be a problem due to decreases in the Medicare Conversion Factor and other congressionally mandated cuts. Congress should provide an annual inflation-based payment update tied to the Medicare Economic Index (MEI) and oppose efforts to use sequestration and PAYGO rules to offset unrelated congressional spending.
• Prior authorization reform: The Committee should work to reduce the burden of prior authorization requirements by supporting the Improving Seniors’ Timely Access to Care Act which will likely be reintroduced this Congress in substantially the same form as last year.
• Telehealth: While many telehealth flexibilities have been extended until Dec. 31, 2024, there is a critical need for permanent telehealth reform, including removing geographic and originating site restrictions, allowing permanent coverage of audio-only services, and reimbursing telehealth at an appropriate rate.
• Advancing value-based care: Congress should work with stakeholders to advance value-based care by improving alternative payment models (APMs) through offering proper incentives, support, and flexibility.

The letter also discussed the importance of strengthening graduate medical education programs to alleviate the projected shortage of doctors in the coming years. MGMA Government Affairs will continue to advocate with the HELP Committee and the rest of Congress for commonsense policies to help mitigate the healthcare workforce shortage.

CMS ISSUES UPADTED GUIDANCE ON NO SURPRISES ACT INDEPENDENT RESOLUTION PROCESS 

On Mar. 17, 2023, certified Independent Dispute Resolution (IDR) entities resumed making payment determinations for disputes that occurred on or after Oct. 25, 2022, under the No Surprises Act (NSA) IDR process. Previously, the Administration paused all payment determination on Feb. 10, 2023, and instructed certified IDR entities to recall any payments issued on or after Feb. 6, 2023. On Feb. 27, 2023, certified IDR entities were instructed to resume making payment determinations for disputes occurring before Oct. 25, 2022.

These actions were taken by the Centers for Medicare & Medicaid Services (CMS) as a result of a Federal District Court vacating part of CMS’ rule for IDR entities determining the payment amount in disputes between health plans and providers. The Texas Medical Association brought a lawsuit challenging CMS’ methodology for calculating the Qualifying Payment Amount (QPA) as favoring health plans, and the judge ruled in favor of providers. The Administration has instructed certified IDR entities to resume making payment determinations following revised guidance CMS issued for determinations on or after Oct. 25, 2022. CMS released updated guidance for disputing parties as well regarding items or services furnished on or after Oct. 25, 2022.

CMS also stated that on Mar. 17, 2023, disputing parties will receive a majority of their payment determinations from the IDR portal. There are other lawsuits still ongoing related to different parts of the NSA that MGMA Government Affairs is monitoring. MGMA is in the process of updating our NSA resource.