News

MGMA COMMENTS ON PRIOR AUTHORIZATION AND INTEROPERABILITY PROPOSED RULE

On Monday, MGMA submitted comprehensive comments to the Center for Medicare & Medicaid Services (CMS) on its proposed rulemaking to reform prior authorization and interoperability within Medicare Advantage (MA) and several other payers. CMS proposed to make numerous changes such as implementing a process to facilitate prior authorizations, requiring affected payers to publicly publish aggregated prior authorization data, and more. MGMA offered the following key recommendations:

• Finalize the inclusion of MA plans in the scope of the rule,
• Finalize the proposal to require plans to provide specific reasons for prior authorization denials,
• Shorten the proposed timeframes to 48 hours for standard prior authorizations and 24 hours for expedited prior authorizations,
• Encourage the use of gold-carding programs in the MA program, and
• Not link electronic prior authorization requirements to CMS’ Quality Payment Program (QPP).

CMS will now review comments submitted by the public before it finalizes the rule. Reforming the prior authorization process has long been one of MGMA’s top priorities. It is our hope that CMS will include MGMA's recommendations in its final rule and expeditiously publish it later this year.

HHS' BUDGET REQUEST FOR FY 2024

Last Thursday, President Biden released his budget for fiscal year (FY) 2024. The Department of Health and Human Services (HHS) proposed $144.3 billion in discretionary and $1.7 trillion in mandatory budget authority. HHS’ section of the budget focused on addressing the following challenges the agency identified:

• Addressing a growing behavioral health crisis,
• Preparing for future health threats,
• Strengthening insurance coverage and lowering health care costs,
• Increasing funding to the Indian Health Service,
• Improving the well-being of children, families, and seniors,
• Growing the health workforce,
• Improving departmental operations, and
• Advancing research to improve health.

Agencies posted their budget justifications to Congress on Monday. CMS specifically identified three key initiatives regarding opioid and substance use disorders, health equity, and nursing homes in its 2024 congressional justification. As a reminder, the President’s budget is meant to be a messaging tool, especially in a divided Congress. It does not have the force of law and Congress will work through the appropriations process to fund the federal government in the coming months.

CMS PROVIDES 2021 QPP PERFORMANCE INFORMATION

CMS has updated the 'Doctors and Clinicians' section of Medicare Care Compare and the Provider Data Catalog (PDC) with new Quality Payment Program (QPP) performance information for 2021. The Care Compare website is meant to allow for Medicare patients and caregivers to compare doctors, clinicians, accountable care organizations, and groups enrolled in Medicare.

CMS is required to report Merit-based Incentive Payment System (MIPS) eligible clinicians’ final scores, performance scores under each MIPS performance category, and the names of eligible clinicians in Advanced APMs. CMS is also required, to the extent feasible, to report the names and performance of Advanced APMs. The performance information is shown under percent performance scores, checkmarks, and measure-level star ratings.

BPCI ADVANCED MODEL 2024 APPLICATION PORTAL OPEN

On Feb. 21, the Centers for Medicare & Medicaid Services (CMS) opened the application portal for year 7 (2024) of the Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model. This model was set to end on Dec. 31, 2023, but CMS announced a two-year extension last October. CMS has requested applications from Medicare Accountable Care Organizations (ACOs), suppliers, and Medicare-enrolled entities for participation in the model starting Jan. 1, 2024.

New convener applicants must be an ACO or Medicare-enrolled entity, while current model participants can continue participation by signing an amended and restated participation agreement for model year 7. Former participants can apply as a convener, non-convener, or episode initiator under a convener. The application portal will stay open for 100 days and close on May 31, 2023, at 5 p.m. ET. More information is available on the BPCI Advanced applicant resources page.

FEDERAL POLICY SESSION AT MEDICAL PRACTICE EXCELLENCE: FINANCIAL & OPERATIONS CONFERENCE

Planning on attending Medical Practice Excellence: Financial and Operations Conference next month in Orlando? You won't want to miss the Washington Policy Outlook (Monday, March 20, from 11:15 a.m. to 12:15 p.m. ET) where MGMA Government Affairs will fill you in on the latest federal policy developments impacting medical practice operations, including changes to the 2023 payment and quality rules, the status of surprise billing and transparency requirements, and other key regulatory changes. MGMA Government Affairs will also give an update on congressional activity that has the potential to impact group practices and recent #MGMAAdvocacy efforts. Attendees will have the opportunity to ask questions at the conclusion of this presentation.

JOIN MGMA'S GOVCHAT ONLINE MEMBER COMMUNITY

By signing up for our GovChat online community, MGMA members have the benefit of engaging with both colleagues and the MGMA Government Affairs team on current regulatory and legislative developments. Recent discussion topics include surprise medical billing, prior authorization "gold carding" legislation, and our 2023 policy priorities.

Sign up for GovChat today to join the #MGMAAdvocacy discussion!

BIDEN ADMINISTRATION TO END COVID-19 PHE on MAY 11

The Biden Administration announced that it plans to end the COVID-19 public health emergency (PHE) on May 11, 2023. This decision comes after multiple renewals over the past three years. MGMA appreciates that the Administration heeded our call to provide at least 90-days’ notice prior to concluding the PHE. The end of the PHE will have ramifications for a variety of flexibilities afforded by the pandemic over the last several years, such as HIPAA penalty waivers, controlled substance prescription waivers, and COVID-19 testing and treatment coverage.

For more information on the flexibilities that will conclude along with the PHE, download MGMA’s member-exclusive resource .

MGMA SUBMITS FEEDBACK ON THE CONNECT FOR HEALTH ACT

On Monday, MGMA sent feedback to the Senate Telehealth Working Group and House Telehealth Caucus on a potential reintroduction of the CONNECT for Health Act (CONNECT Act). Previous iterations of the CONNECT Act aimed to permanently expand access to telehealth services and the last version was endorsed by more than 170 organizations including MGMA.

MGMA offered the following suggestions to include in a new version of the bill:

• Remove geographic and originating site restrictions,
• Allow permanent coverage of audio-only services,
• Reimburse telehealth visits at an appropriate rate,
• Preserve the patient-physician relationship,
• Eliminate the in-person requirement for mental telehealth services, and
• Provide training and resources to practices.

With the Administration announcing its plans to end the COVID-19 PHE on May 11, there is ample opportunity to permanently install vital telehealth flexibilities to promote access to high-quality care.

 

ADVOCACY IN ACTION: MGMA JOINS CMS FOR ROUNDTABLE ON PRIOR AUTHORIZATION REFORM

On Jan. 17, the Centers for Medicare & Medicaid Services (CMS) convened a stakeholder roundtable to discuss prior authorization and several recent proposals for reform. MGMA was one of a handful of organizations invited to participate in discussion alongside  CMS Administrator Chiquita Brooks-LaSure and U.S. Surgeon General Dr. Vivek Murthy. During the meeting, MGMA Board Chair Jeff Smith and SVP of Government Affairs Anders Gilberg shared feedback on the many challenges medical groups face surrounding prior authorization. MGMA will share comments on the proposed rules to reform prior authorization in the coming months.

TODAY: HEALTH CARE VALUE WEEK PANEL FEATURING MGMA

Health Care Value Week is underway!  This multi-day event includes a variety of no-cost educational content, including presentations from CMS leadership and other key industry leaders with the goal of developing a path forward to advance opportunities to participate in value-based care models. Of note, we hope you can tune in at 1 p.m. ET today for a panel on barriers and opportunities for independent physicians in value-based care featuring MGMA’s SVP of Government Affairs Anders Gilberg.

For more information, including a full schedule of events and registration links, please visit the Health Care Value Week website.

MGMA TO CONGRESS: SUPPORT PHYSICIAN PRACTICES

On Monday, MGMA and over 100 other leading organizations signed a letter urging Congress to work with stakeholders to explore long-term physician payment issues. Since 2021, medical groups have faced annual cuts due to the effect of budget neutrality requirements stemming from the revaluation of certain codes. The combination of these yearly cuts paired with inflation is unsustainable. We ask Congress to begin holding hearings as soon as possible to explore potential payment solutions to ensure that America’s seniors continue to receive access to high-quality care.

COVID-19 PHE RENEWED

U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra renewed the COVID-19 public health emergency (PHE) yesterday. This renewal extends the PHE through mid-April 2023 and has implications for Medicare telehealth, COVID-19 testing, and other waivers. HHS has reiterated its promise to give a 60 days’ notice before letting the PHE expire.

While many telehealth flexibilities are tied to the PHE, it is important to note that the recently passed Consolidated Appropriations Act, 2023, does ensure certain ones will remain in effect through Dec. 31, 2024, regardless of PHE status. More information may be found in MGMA Government Affairs’ newly updated telehealth resource.

CMS PROPOSES FIVE NEW MVPS FOR 2024

2023 is the first year clinicians may voluntarily report under a MIPS Value Pathway (MVP), with the Centers for Medicare & Medicaid Services (CMS) having finalized 12 MVPs for 2023. On Monday, as part of the “MVP Candidate Feedback Process,” CMS announced it is accepting comments on the following five draft MVPs under consideration for 2024:

1.   Quality Care in Mental Health and Substance Use Disorder

2.   Prevention and Treatment of Infectious Disorders Including Hepatitis C and HIV

3.   Musculoskeletal Care and Rehabilitative Support

4.   Quality Care for Otolaryngology

5.   Focusing on Women’s Health

Comments on these five draft MVPs will be accepted through Feb. 8, 2023. CMS will display feedback it received for each MVP on the Quality Payment Program website, but won’t respond to those submitting feedback directly. If you would like to provide feedback on any of the draft MVPs, additional information may be found here.

For more information on MVPs, check out MGMA Government Affairs’ newly updated resource.

PRF REPORTING PORTAL OPEN FOR REPORTING PERIOD 4

The Provider Relief Fund (PRF) Reporting Portal is now open for reporting on use of funds in Reporting Period 4. Providers who received one or more PRF (General or Targeted) and/or American Rescue Plan Rural payments exceeding $10,000, in the aggregate, during the fourth Payment Received Period (July 1 to December 31, 2021) must report on their use of funds by March 31, 2023. First time reporters can get started by registering in the PRF Reporting Portal. If a reporting entity has previously reported, they do not need to register again and may log into the Portal with their username, TIN, and password. For more information visit the PRF Reporting webpage.

NEW MEMBER RESOURCE ON OMNIBUS PROVISIONS IMPACTING MEDICAL GROUPS

On Dec. 29, 2022, President Biden signed the Consolidated Appropriations Act, 2023 (CAA, 2023), into law, which contained a handful of provisions that impact medical group practices, including mitigating provider reimbursement cuts under Medicare for two years and extending certain telehealth flexibilities. To assist members, MGMA Government Affairs created a high-level resource outlining those provisions included within the CAA, 2023, likely to have an effect on practice operations.

Interested in additional information on 2023 policies? Make sure to review MGMA’s 2023 Physician Fee Schedule Analysis and 2023 Medicare Outlook webinar recording!

MIPS EXTREME AND UNCONTROLLABLE CIRCUMSTANCES APPLICATION DEADLINE EXTENDED

The Centers for Medicare and Medicaid Services (CMS) extended the deadline to file a 2022 MIPS Extreme and Uncontrollable Circumstances (EUC) hardship exception application for those citing COVID-19 as a triggering event until March 3, 2023 at 8 p.m. ET. The deadline originally was Jan. 3, 2023. CMS notes that applications received between Jan. 3, 2023 and March 3, 2023 will not override submitted data for individuals, groups, and virtual groups. Additionally, APM Entities participating in MIPS APMs can submit a MIPS EUC exception application, but should note the following differences:

• APM Entities are required to request reweighting for all performance categories.
• At least 75% of the MIPS eligible clinicians in the APM Entity will need to qualify for reweighting in the Promoting Interoperability performance category.

Data submission for an APM Entity won't override performance category reweighting from an approved application.

ADDITIONAL GOOD FAITH ESTIMATE GUIDANCE RELEASED

CMS has released additional guidance regarding the good faith estimates (GFE) for uninsured (or self-pay) individuals as established in the No Surprises Act. The FAQs cover how federally qualified health centers with sliding fee discounts can comply with GFE requirements, when an abbreviated GFE can be used, and what types of contact information providers should include in a GFE. CMS includes a sample template that group practices can utilize for abbreviated GFEs.

For more information on the No Surprises Act, please review MGMA’s updated member-exclusive resource.

CONGRESS RELEASES YEAR-END LEGISLATION, ADDRESSING MEDICARE CUTS AND TELEHEALTH

Earlier this week, Congress released the text of their year-end spending package, which contains a handful of healthcare provisions that will impact medical groups.

Medicare physician payment: The legislation averts 6.5% of the scheduled 8.5% reduction to physician reimbursement in Medicare, resulting in an approximate 2% cut to the Medicare conversion factor for 2023. By way of background, in 2021, CMS shifted funds in the physician fee schedule to pay for an increase in work RVUs, which raised reimbursement for office visits. This shift resulted in a decrease to the conversion factor due to a statutorily mandated budget neutrality adjustment. Congress provided funds to offset the adjustment in 2021 and partially offset it again in 2022. Going into 2023, we expected a cut of 8.5%, resulting from both a decrease to the conversion factor (4.5%) and PAYGO cut (4%). For the third year in a row, we’ve urged Congress to address the de facto cuts — this year in the form of adding 4.5% back into the fee schedule and waiving PAYGO. Unfortunately, despite 10,000 letters from MGMA members, Congress did not have the appetite to fully waive budget neutrality requirements to address the slated 4.5% cut. Instead, Congress will only partially mitigate it by allowing a 2% cut in 2023. This is in addition to legislation waiving the 4% PAYGO for 2023 and 2024. MGMA has voiced its disappointment that Congress is allowing a 2% cut to occur in 2023 and will continue working to find a more sustainable and comprehensive solution.

Alternative Payment Models (APMs): The 5% incentive bonus is set to expire at the end of this year. The legislation would extend the bonus for an additional year, through 2023, at 3.5%.

Telehealth: Many telehealth waivers, including being able to treat a patient in their home, were extended through 2024. This is positive development supported by MGMA to ensure continuity from pandemic-era telehealth policies.

Lab cuts: Pending the passage of this legislation, practices will receive a one-year reprieve from the laboratory cuts of up to 15% that would have gone into effect in January 2023. This provision was also supported by #MGMAAdvocacy.

We expect Congress to pass this legislation into law by Friday. We will let you know if Congress modifies the current text.

HRSA BEGINS ISSUING REPAYMENT NOTICES

The Health Resources & Services Administration (HRSA) began issuing Repayment Request Notices to Provider Relief Fund (PRF) recipients who must repay funds. If your practice receives a Repayment Request Notice based on a HRSA finding of non-compliance or the results of an audit, you can request a Decision Review. As a reminder, the Decision Review is not related to payment calculations and determinations. If you believe your payment was incorrectly calculated, visit the Payment Reconsideration page.

More information about the repayment process can be found here.

NEW RESOURCES AVAILABLE FROM MGMA GOVERNMENT AFFAIRS

As we approach 2023, many new federal policies will take effect that will impact your medical group. MGMA Government Affairs has updated and created new resources to help your practice prepare! Take advantage of these member-exclusive resources today:

• 2023 MIPS Value Pathways (MVPs) resource *new*
• No Surprises Act resource *updated*
• 2023 Medicare Outlook webinar *new*
• 2023 Medicare Physician Fee Schedule Analysis

MGMA members can reach out to govaff@mgma.org with any questions regarding these new and updated resources.

MGMA AND PARTNER ORGS. URGE CONGRESS TO PREVENT FULL 4.5%

On Monday, MGMA and over 100 other healthcare stakeholder organizations sent a letter to congressional leadership urging action to avert the entire 4.5% reduction to Medicare payment rates scheduled to take effect Jan. 1, 2023. The letter illustrates the severity of this pending cut and the negative impact it will have on practices, especially in light of current inflationary pressures. As the Medicare physician fee schedule is the only Medicare payment system without an annual inflationary update, the pending 4.5% reduction will only exacerbate current financial concerns.

MGMA is continuing to advocate against this harmful reduction and for permanent payment reforms. Join in #MGMAAdvocacy today by sending a letter to your members of Congress to pass legislation to stop the full 4.5% payment reduction from taking effect.

CMS FURTHER DELAYS CONVENING/CO-PROVIDER REQUIREMENTS FOR GOOD FAITH ESTIMATES

Following months of #MGMAAdvocacy, CMS announced that they are extending enforcement discretion, pending future rulemaking, for the convening/co-provider good faith estimate (GFE) requirements. Therefore, CMS will  NOT begin enforcing these requirements on Jan. 1, 2023. If enforced, practices acting as “conveners” would be responsible for requesting and compiling estimates from each co-provider or co-facility expected to provide a service in connection with the convening provider or facility’s service. This is in addition to the convening provider’s other GFE responsibilities. MGMA previously urged CMS to continue to exercise enforcement discretion past Jan. 1, 2023, due to challenges associated with transferring this information and the tight timeframes.

As a reminder, the advanced explanation of benefits (AEOB) requirements are similarly not being enforced pending further rulemaking.

CMS PROPOSES PRIOR AUTHORIZATION REFORM IN MEDICARE ADVANTAGE CUT TO MEDICARE PAYMENT RATES

On Tuesday, CMS released its proposed rule on electronic prior authorization (ePA) after months of MGMA urging the agency to do so. If finalized, this rule would apply to Medicare Advantage (MA) organizations, state Medicaid and CHIP Fee-for-Service (FFS) programs, Medicaid managed care plans and Children's Health Insurance Program (CHIP) managed care entities, and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs). The rule proposes, in part, to require the aforementioned plans to: (1) Provide a clear reason for PA denials, (2) Publicly report on PA approvals, denials, and appeals, (3) Respond to PA requests within certain timeframes (72 hours for urgent, 7 days for non-urgent), and (4) Implement and maintain an API to support and streamline the PA process. 

MGMA will comment on this proposed rule and work with CMS to further refine it. We are also hopeful that this rule will help get MGMA-supported PA legislation (the Improving Seniors' Timely Access to Care Act) across the finish line before the end of the year. Please continue to urge your members of Congress to support this legislation by sending a letter through our Contact Congress portal.

MGMA SVP OF GOVERNMENT AFFAIRS NAMED ONE OF THE HILL'S 2022 TOP LOBBYISTS

Yesterday, MGMA’s Senior Vice President of Government Affairs Anders Gilberg was named one of The Hill’s 2022 Top Lobbyists — an award recognizing “the corporate lobbyists, hired guns, association leaders and grassroots activists who leveraged their expertise and connections to make a difference in the nation’s capital this year.” This prestigious recognition is reflective of the work Anders and MGMA have undertaken this past year representing the interests of our members and medical groups nationwide.

The Government Affairs team would like to extend a huge ‘thank you’ to everyone who has participated in #MGMAAdvocacy this past year, as you all undoubtedly contributed to this win!

Your guide to 2023 Medicare payment rules

The Centers for Medicare & Medicaid Services released its final 2023 Physician Fee Schedule (PFS) rule, which includes payment and coding updates for Medicare services, modifications to telehealth, and changes to the Quality Payment Program.

MGMA Government Affairs reviewed, analyzed, and distilled over 2,000 pages of the final rule to draft this member-benefit analysis. The resource breaks down significant payment and quality reporting changes for 2023 and offers practical takeaways for busy medical group practice executives. Key regulatory provisions include:

• Setting the CY 2023 PFS conversion factor at $33.0607 (a reduction of 4.47%) and the CY 2023 national average anesthesia conversion factor at $20.6097. MGMA is advocating for a legislative fix to address the reimbursement cuts resulting from the lower conversion factor;
• Delaying the split/shared E/M billing policy until CY 2024, permitting the billing clinician to bill for services based on history, exam, medical decision marking or time in 2023;
• Continuing payment for Medicare telehealth services that are temporarily included on the telehealth list for 151 days following the conclusion of the COVID-19 public health emergency and maintains payment parity between in-person and telehealth visits through 2023;
• Permitting auxiliary personnel to furnish behavioral health services incident to a physician or NPPs services under general instead of direct supervision;
• Increasing Qualifying APM Participant (QP) and partial QP threshold in performance year 2023; and
• Finalizing 5 new MIPS Value Pathways (MVPs), for a total of 12 MVPs available for voluntary reporting in 2023.

DOWNLOAD THE ANALYSIS!

Interested in learning more about the updates to Medicare physician payment and quality reporting that will be in effect come Jan. 1, 2023? Join MGMA Government Affairs on Dec. 13 at 1 p.m. ET for our member-exclusive 2023 Medicare Outlook webinar to gain insights about payment and policy changes outlined in the final 2023 PFS rule. Register here.

MGMA sends Congress year-end legislative recommendations

On Monday, MGMA sent a letter to congressional leadership urging them to address significant Medicare cuts and other important healthcare policies before the end of this year. The letter highlights current issues with Medicare reimbursement that projected payment cuts will exacerbate and asks Congress to act by:

• Offsetting the 4.47% reduction to the Medicare physician conversion factor;
• Waiving the 4% statutory Pay-As-You-Go sequester; and,
• Extending the 5% alternative payment model (APM) incentive payment for six additional years.

Further, MGMA encouraged Congress to pass additional commonsense legislation to address significant administrative burdens impacting group practices and improve the timeliness of clinical care delivery. These recommendations included passing the Improving Seniors’ Timely Access to Care Act, extending telehealth waivers for at least two years after the conclusion of the public health emergency, passing the Saving Access to Laboratory Services Act, and appropriating additional funds to continue rewarding high performing clinicians within the Merit-based Incentive Payment System (MIPS).

Visit MGMA's Contact Congress portal to send a letter to your legislators on these important issues!

MGMA submits feedback on AEOB requirements

On Tuesday, MGMA submitted feedback to the Department of Health and Human Services about the upcoming advanced explanation of benefits (AEOB) requirements stemming from the No Surprises Act. The AEOB policies would require group practices to send good faith estimates to health plans, thereby allowing the plans to generate AEOBs to send to patients. As a reminder, these requirements are not being enforced until rulemaking is completed. MGMA encouraged HHS to not enforce the AEOB requirements until there are workable solutions that are developed, tested, and implemented as well as to continue soliciting input and working with medical groups to implement these solutions.

JOIN MGMA FOR OUR 2023 MEDICARE OUTLOOK WEBINAR

Interested in learning more about the updates to Medicare physician payment and quality reporting that will be in effect come Jan. 1, 2023? Join MGMA Government Affairs on Dec. 13 at 1 p.m. ET for a for our member-exclusive 2023 Medicare Outlook webinar to gain insights about payment and policy changes outlined in the 2023 Medicare Physician Fee Schedule final rule. Additionally, we’ll provide details about MIPS reporting requirements, the MIPS Value Pathways implementation timeline, and APM participation and reporting options for 2023. The hour-long session will conclude with a discussion of MGMA’s advocacy initiatives and an interactive Q&A session with Government Affairs staff.

For more information, or to register, please click here.