On July 27 EDPMA joined medical societies urging Congress to pass legislation that provides at least a 4.5% CF adjustment for 2023 and waives the 4% statutory PAYGO requirement. We also ask for legislation to provide a one-year inflationary update based on the Medicare Economic Index. These important policy changes will undoubtedly provide our members with crucial short-term fiscal stability while simultaneously laying the foundation for necessary long-term payment reforms. The letter can be found here.
McLean, Virginia – The Emergency Department Practice Management Association (EDPMA) is concerned that payers are denying payments to emergency medicine physicians for essential and lifesaving care they provide to patients. EDPMA believes that emergency physicians should be able to deliver high-quality, cost effective care in the emergency department and that payers should reimburse highly-trained emergency physicians based on a patient’s presenting symptoms.
However, many payers prioritize profits over patient care with the systemic practice to unnecessarily delay, deny, or reduce payments. EDPMA believes this is wrong and advocates on the regulatory, federal, and state levels to combat this practice on behalf of its members.
EDPMA also supports the efforts of our member organizations to advocate on behalf of their emergency physicians, such as Fremont Emergency Services’ litigation to hold UnitedHealthcare accountable for its policy to withhold payment to ER doctors after services have been rendered. In this vein, we support our colleague’s efforts to advocate for emergency physicians and patients by any means necessary, including litigation.
“EDPMA continues to hold payers accountable for systemic practices that do not acknowledge or compensate for medical decision making in the emergency department,” says Don Powell, DO, FACEP, EDPMA Chair of the Board. “We strongly believe that emergency physicians should be fairly reimbursed for the delivery of emergency care, and payers should do their part to not undermine the emergency medical health care delivery system or the overall health of our healthcare system. EDPMA is in the business of emergency medicine and will continue to advocate for its members and patients.”
The Emergency Department Practice Management Association (EDPMA) is the nation’s largest professional physician trade association focused on the delivery of high-quality, cost-effective care in the emergency department. EDPMA’s membership includes emergency medicine physician groups of all sizes, as well as billing, coding, and other professional support organizations that assist healthcare providers in our nation’s emergency departments. Together, EDPMA’s members deliver (or directly support) health care for about half of the 146 million patients that visit U.S. emergency
departments each year. Visit http://www.edpma.org.
703.506.3282 (direct) l 817.905.3310 (cell)
This afternoon, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2023 Medicare Physician Fee Schedule (MPFS) proposed rule. For CY 2023, CMS proposes an MPFS conversion factor of $33.0775. That represents a 4.42% reduction from the CY 2022 MPFS conversion factor due to the expiring 3.0% boost to the conversion factor provided by Congress for CY 2022 as well as an additional budget neutrality adjustment generated by the CY 2023 proposed policies.
- Emergency Medicine Overall Impact. CMS estimated that the overall impact of the rule on emergency medicine is a 1% increase in payments. However, note that this estimate does not factor in the expiring CY 2022 congressionally-mandated 3% boost to the conversion factor.
- ED E/M Codes: Generally speaking, CMS proposes to adopt the revised CPT documentation guidelines for emergency department (ED) evaluation and management (E/M) visits. These changes are intended to align documentation for all E/M code sets (other than critical care services) with the documentation guidelines adopted for office and outpatient E/Ms in CY 2021. (For more information on the ED E/M documentation guideline changes coming January 1, 2023, see information from AMA CPT via this link.)
Because of these documentation guideline changes, the AMA RUC also embarked on a revaluation of all affected codes sets. In this proposed rule, CMS proposes to accept the values for emergency department (ED) evaluation and management (E/M) services as recommended by the AMA RUC for CPT 99281, 99282, 99283, and 99285. However, CMS rejected the RUC recommendation of 2.60 for CPT 99284 and instead proposes to maintain the current work RVU of 2.74.
- Split (or Shared) Visits. CMS had previously finalized a new January 1, 2023 billing policy for instances in which a physician delivers an E/M service along with a non-physician practitioner. As EDPMA requested, CMS has delayed the policy that would have based the determination of the billing practitioner solely on time. This policy is proposed for delay through January 1, 2024 while CMS collects additional input.
- QPP. Per usual, CMS proposes modifications to the reporting requirements under the Quality Payment Program (QPP), including the Merit-based Incentive Payment System. As a reminder, CY 2023 reporting under the QPP will affect payment adjustments for services furnished in CY 2025.
EDPMA will continue to analyze the proposed rule and provide additional details. EDPMA plans to comment on the proposed rule before the end of the 60-day comment period.
- A link to the full rule can be found here.
- A CMS press release is available here.
- A CMS fact sheet can be accessed here.
- CMS also provided additional resources on the CY 2023 QPP policies in a zip file available here.
Yesterday, EDPMA and ACEP sent a letter to Departments of HHS, Labor and Treasury asking for action to ensure patients are taken out of the middle of payment disputes with health plans. This letter is a follow-up to the April 25 letter
and meeting with CCIIO
where EDPMA and ACEP shared continued concerns about emergency physicians’ difficulty in obtaining information from plans and insurers as required by the No Surprises Act. The full letter can be found here
We will continue to monitor NSA implementation issues and advocate for you!
EDPMA in our partnership efforts with the American College of Emergency Physicians (ACEP) have worked to highlight the issues our members are experiencing with health plan compliance with their obligations under the No Surprises Act. After sending multiple letters with examples of health plan non-compliance and meeting with staff from the Center for Consumer Information and Insurance Oversight (CCIIO), EDPMA is pleased to announce that CCIIO has released a new guidance document, Federal Independent Dispute Resolution Process Checklist of requirements for group health plans and group and individual health insurance issuers.
The full document can be accessed here.
EDPMA’s members consistently report that health plans are not providing federally required information to bill patients’ out-of-network services and to proceed with the federal Open Negotiations and Independent Dispute Resolution (IDR) processes that are part of the No Surprises Act. To advocate on your behalf, we wrote a letter to federal agencies last month that provided: 1) specific examples of health plan non-compliance; and 2) policy recommendations that would help address these non-compliance issues. EDPMA thanks our members who shared their redacted data to support this advocacy effort.
Last week, EDPMA and ACEP met with the Center for Consumer Information and Insurance Oversight (CCIIO) at the Centers for Medicare & Medicaid Services (CMS) staff to follow-up on our letter. During the meeting, we described to CCIIO what specific health plan non-compliance issues we are experiencing, provided specific recommendations, and also requested additional guidance on how we should proceed with the Open Negotiations and IDR processes when there is limited or missing information from health plans (information that was required by the first interim final rule implementing the No Surprises Act). We also emphasized the critical need for strong enforcement to ensure health plans provide information as required by law.
CCIIO made two important points about complaints:
- If a complaint remains unresolved and the timelines around the Open Negotiation and IDR processes become difficult to adhere to, disputing parties can file for an extension.
- You are allowed to “batch” complaints against one health plan. In other words, instead of submitting a complaint for each individual claim, you can submit all the complaints against one health plan at once. This may help save time and speed up the time in which your complaints are processed and adjudicated by CMS.
CCIIO staff stated that they heard many of these issues before and have received many complaints from providers that health plans are not providing all the required information. CCIIO also claimed they resolved about 25% of all complaints, and there is a significant backlog of unresolved complaints. Further, they stated that when a complaint is resolved, they request documentation from the health plan and continue to work with them to systematically resolve similar complaints moving forward. While CCIIO confirmed they are hosting internal conversations about how to enforce non-compliance, they did not offer specifics on enforcement processes or outcomes.
We believe the meeting was productive and we are reassured that CCIIO is acutely aware of these issues and is taking them seriously. Because CCIIO did not commit to adopting our policy recommendations, we will continue to follow-up with CCIIO on these requests.
As always, EDPMA has your back by advocating on your behalf and providing the resources you need to manage a successful business.
As a reminder, you can submit billing complaints by clicking here or by contacting the No Surprises Help Desk at 1-800-985-3059.
As the saying goes, “Data is King (or Queen)!” And legislators and regulators are moved to action by data and not anecdotes.
In conjunction with ACEP to better advocate for our members and the emergency medicine specialty, we are collecting data on your out-of-network (OON) payments focused on the Qualifying Payment Amount (QPA). This project will evaluate whether major payors are following the law by providing QPAs in writing for each CPT code that was paid or denied, assess the prevalence and size of variations between QPAs and the “Allowed Amounts” for OON payments and more. See the data collection Excel tool and Frequently Asked Questions about this project.
We understand there are questions about the requested data, how the data will be used and concerns about privacy and antitrust issues.
We get it!
That’s why EDPMA will host an informational webinar this Monday, May 9 at 1pm EDT to answer these questions and more for compliance managers, data analysists, business intelligence teams and skeptics. This webinar is open to both members and non-members.
Ed Gaines, JD and Greg Hufstetler CPA, the outside data consultant, will review project details and answer your questions.
For more information and to register, click here.
EDPMA’s next educational webinar, “The Federal IDR Portal Is Launching – Now What?,” will be held on Monday, April 18 at 1:00 pm eastern. Please note that registration will close at 12 pm eastern on Monday, April 18.
In addition to important new patient protections for emergency and certain non-emergency services, a key feature of the No Surprises Act is the introduction of a Federal IDR system to resolve payment disputes between providers and payers when state law provides no mechanism for doing so.
The departments tasked with implementing the law have laid out a plan to administer the IDR provisions via a “Federal IDR portal.” The launch of the portal has been delayed as the federal agencies tasked with implementing the IDR system have worked through launch issues in the wake of the ongoing litigation related to the IDR provisions of the No Surprises Act, even while disputes have begun to work through timelines that would otherwise make them eligible for initiating the IDR process.
Per HHS, the Federal IDR portal should launch the week of April 11. To ensure our members are fully prepared, EDPMA will host a member webinar to share available information on the IDR portal launch and take member questions.
This is a member-only benefit.
Click here for more information and to register.
On April 4, EDPMA sent a letter to CMS asking for the agency to revisit its CY 2023 split/shared policies. The letter can be found here.