News

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. 

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.