On Monday, January 23, 2023, EDPMA joined a coalition of over 100 organizations urging Congress to reform the Medicare payment system. The letter can be found here.
Author Archive for arobertson – Page 5
Categories : News
On Thursday, January 19, 2023, EDPMA and ACEP sent a letter to the Tri-Agencies thanking them for the early January conversation and providing additional input and more detailed recommendations. The letter can be found here.
On Monday, January 23, 2023, ACEP issued a press release regarding the letter and it can be found here.
Categories : News
Top Medical Associations Oppose 600% Independent Dispute Resolution Fee Increase, Call on Congress for Oversight
By arobertson
Friday,
January
13th,
2023
WASHINGTON, DC, January 13, 2023 – The Radiology Business Management Association (RBMA), Emergency Department Practice Management Association (EDPMA), Healthcare Business Management Association (HBMA) and Medical Group Management Association (MGMA) all strongly oppose the U.S. Centers for Medicaid and Medicare Services (CMS) 600% administrative fee increase to utilize the Independent Dispute Resolution (IDR) process provided by the No Surprises Act (NSA). The Associations represent radiology and emergency healthcare clinicians across the country, and they call on CMS to immediately reverse this decision and on Congress to initiate oversight proceedings on this executive action.
“RBMA fully supports Congress’ intention of the NSA to protect patients from unexpected medical bills, and our physicians are committed to providing affordable, quality care to their patients across the country,” said Bob Still, Executive Director of the Radiology Business Management Association (RBMA). “As such, this 600% fee increase under the NSA puts physicians in the middle of health plans and CMS’ inadequate implementation process of those plans. By pricing out the method for dispute resolution with this excessive fee, our providers’ ability to perform important services, like cancer screenings, will be significantly hindered and inevitably hurt the healthcare of American consumers.”
“While EDPMA understands CMS’ need to address the IDR backlog, exorbitant fees are simply not the answer. These abrupt, inappropriate increases unnecessarily burden emergency medicine clinicians and significantly deter clinician’s access to the method of dispute resolution provided by Congress. This is another substantial mis-step that fails to address fundamental operational and policy-related issues involved in the No Surprises Act,” said Don Powell, DO, FACEP, EDPMA Chair. “CMS’s actions prevent the level playing field provided in the law, and contrary to the law’s interests, will drive more payer-driven contact terminations, while crippling the cash flow that supports emergency care for patients.”
“Increasing the administrative fees for the IDR process by 600% is not the appropriate way to address the backlog of IDR disputes,” said Landon Tooke, CHC, CPCO, President of HBMA’s Board of Directors. “The new fee – which is not reimbursed to the initiating party – is higher than many of the disputed payment amounts. This unfairly disincentivizes clinicians from utilizing the IDR process and does not align with how Congress intended this process to be used. The higher fee does not address the root cause of the backlog, which is health plans forcing many practices out of their networks which puts a greater burden on the IDR process. While we understand the need to address the high volume of initiated disputes, health plans share the responsibility to reduce the backlog by properly communicating if the NSA protections apply to a specific scenario and by negotiating in good faith during the open negotiation window.”
“MGMA supports the goals underpinning the No Surprises Act — we believe patients should have accurate and timely access to the costs of items and services. However, the law must be implemented in a manner that does not create undue burden on our nation’s medical groups, nor impede practices’ ability to deliver care,” said Anders Gilberg, Senior Vice President of Government Affairs for MGMA. “Increasing the administrative fee for the IDR process will disproportionally effect providers who are already suffering from significant financial strain stemming from staffing shortages, wage inflation, and drastic cost increases across the board. We encourage CMS to swiftly reevaluate the administrative fee, to make it equitable so as to not prohibit medical groups’ ability to initiate the IDR process to settle payment disputes with health plans as granted by the law.”
The Associations call on CMS to fairly rebalance the IDR process, keep administrative fees at fair and stable 2022 levels, and address their unsustainable backlog of claims under NSA. To ensure this appropriate and much needed reform at CMS, the Associations call on the new Congress to initiate oversight proceedings on these processes at CMS.
After first announcing in October 2022 that the 2023 administrative fee would remain stable, in a last-minute move in late December 2022, CMS announced a 600% increase in non-refundable administrative fees for any party to file out-of-network claims disputes through the NSA’s IDR process. Additionally, CMS had previously announced fee increases of up to 117% for IDR entities. The dramatic, unprecedented increase in initial fees with less than a week’s notice disproportionately affects providers, favors health plans, and will hurt consumers.
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About RBMA:
The Radiology Business Management Association (RBMA) is an industry-leading organization comprised of more than 2,100 professionals who focus on the business of radiology. RBMA members support diagnostic imaging, interventional radiology and radiation oncology providers in the full spectrum of practice settings. RBMA connects members nationwide to valuable information, education, and practice-related resources and serves as an authoritative industry voice on behalf of shared member interests.
About EDPMA:
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.
About HBMA:
The Healthcare Business Management Association (HBMA), a non-profit professional trade association, is a major voice in the revenue cycle management industry in the United States. HBMA is a recognized revenue cycle management (RCM) authority by both the commercial insurance industry and the governmental agencies that regulate or otherwise affect the U.S. healthcare system. To learn more, visit www.hbma.org.
About MGMA:
Founded in 1926, the Medical Group Management Association (MGMA) is the nation’s largest association focused on the business of medical practice management. MGMA consists of 15,000 group medical practices ranging from small private medical practices to large national health systems representing more than 350,000 physicians. MGMA helps nearly 60,000 medical practice leaders and the healthcare community solve the business challenges of running practices so that they can focus on providing outstanding patient care. Specifically, MGMA helps its members innovate and improve profitability and financial sustainability, and it provides the gold standard on industry benchmarks such as physician compensation. The association also advocates extensively on its members’ behalf on national regulatory and policy issues. To learn more, go to MGMA.com or follow us on LinkedIn, Twitter and Facebook.
RBMA Media Contact:
Will Sweet
[email protected]
EDPMA Contact:
Cathey Wise
703.506.3282 (direct) | 817.905.3310 (cell)
[email protected]
HBMA Contact:
Brad Lund
(877) 640-4262
[email protected]
MGMA Contact:
Emily Dowsett
(703) 376-1134
[email protected]
Categories : News
After Congress passed a one-week continuing resolution (CR) to avoid a government shutdown, legislators released the text of the long-awaited Omnibus in the early hours of Tuesday morning. The 4,155-page legislation must be enacted by Friday December 23rd to avoid a government shutdown.
With regard to Medicare payment, the legislation fully averts the 4% PAYGO sequestration in 2023 and 2024. As to the Medicare Physician Fee Schedule conversion factor, however, the bill provides only 2.5% worth of relief for the almost 4.5% cut scheduled for 2023, leaving providers with an approximately 2% reduction to absorb next year. For 2024, the bill provides only 1.25% worth of relief. Given that the 2024 conversion factor is unknown as of yet, the real-world impact of that 1.25% is more speculative at this time, but it is expected under this provision that physicians will again suffer an additional payment cut in 2024, relative to both 2023 and 2022.
In the final weeks leading up to release of the Omnibus, lawmakers on both sides of the aisle pressured leadership to ensure that the 4.5% conversion factor reduction was averted in full. A bipartisan letter signed by 115 legislators led by Rep. Wild (D-Pa.) and Rep. Miller-Meeks (R-Iowa) requested that both the PAYGO and conversion factor cuts be stopped entirely, noting that these two reductions would be piled onto the 2% Medicare sequestration cut, which resumed on July 1st of this year. Furthermore, the letter stated opposition “to paying for preventing these cuts with additional provider cuts.” The House GOP Doctors Caucus weighed in with another letter to leadership, requesting a solution to the impending Medicare payment cuts. On the Senate side, Sen. Kennedy (R-La.) introduced legislation to avert the full 8.5% cut to Medicare in 2023, but that legislation was objected to by Finance Committee Chairman Wyden (D-Ore.), because the Kennedy bill bypassed the Committee process and because addressing the physician cuts via standalone legislation may jeopardize inclusion of other priorities in the larger year-end legislation.
The Omnibus does contain a two-year extension of pandemic-related Medicare telehealth flexibilities, as well as an extension of a provision allowing coverage of telehealth services in high deductible health plans with Health Savings Accounts. The legislation would also extend separate COVID-related waivers that allow for the treatment of some emergency department patients and inpatients from their home. The legislation also extends (at 3.5%) an expiring 5% bonus for providers participating in alternative payment models.
Physician groups expressed disappointment that Congress would allow any level of reimbursement reduction to go into effect at a time when providers are facing record inflation and staffing shortages, particularly since the legislation extends the 2% Medicare sequester on providers by another year in 2032, to help pay for other priorities in the bill. Overall, the Omnibus contains over $1.6 trillion dollars of spending. The bill is expected to pass by Friday’s deadline without major changes, but EDPMA will closely monitor all amendments and alert members to any relevant changes, if needed.
Looking ahead, EDPMA will aggressively pressure legislators for permanent reform to Medicare payment, since these annual last-minute crises cause instability in the Fee Schedule that affects beneficiary access to care.
Categories : Uncategorized
Updates Released on No Surprises Act Federal IDR Process
By arobertson
Wednesday,
December
21st,
2022
As the Federal agencies tasked with implementing the No Surprises Act continue to work through the backlog of disputes that have been stuck in the IDR process with the contractors hired by the Federal government to administer dispute resolutions (referred to as certified independent dispute resolution entities or IDREs), several recent announcements have been made that are important for providers who are seeking to have disputes resolved under the Federal IDR process.
- IDRE Reselection Process: As has been the case since the initial implementation of the No Surprises Act, under the Federal IDR process, disputing parties must agree on an IDRE to administer the dispute resolution, and where the parties cannot agree, the regulations allow for the federal agencies to randomly assign the IDRE. Until recently, this “back-and-forth” of selecting an IDRE has been primarily conducted via email communications. Beginning on December 12th, the U.S. Department of Health and Human Services (HHS) launched a new web functionality intended to streamline this process during the “initiation of IDR” phase. The new form is referred to as the “IDR Entity Reselection Response Form.” HHS has released an instructional video for disputing parties to familiarize themselves with the new process.
- New Requirement for Parties Challenging IDR Initiation to Provide Documentation: The Centers for Medicare and Medicaid Services (CMS) made a positive announcement that, beginning the week of December 19th, parties that are challenging IDR initiation must now provide documentation in support of their challenge rather than just making unsubstantiated accusations that can slow down the IDR process. As described in the CMS announcement, instances that will now require documentation from health plans when making a challenge to Federal IDR initiation include:
- “Specified State Law or All-Payer Model Agreement”: If an entity attests that a dispute is eligible for a state process to determine the out-of-network rate, the entity must provide: specific citation(s) for the state law or regulation that constitutes a specified state law or all-payer model agreement that applies to the items or services in the dispute; and documentation that confirms that the state law applies, including proof of the health plan type.
- “Open Negotiation Not Completed”: If an entity attests that the open negotiation period was not completed for a dispute, the entity must provide: the date when the open negotiation period will be completed; and documentation that confirms the open negotiation start date.
- “Late IDR Initiation”: If an entity attests that more than four business days have elapsed since the open negotiation period ended, the entity must provide: the date that was the last day in the four business day period after the open negotiation period; and documentation that confirms when the open negotiation period was initiated for the claim or claims subject to the dispute.
- “Not Covered by NSA”:
- If an entity attests that a dispute includes items or services not covered under the No Surprises Act, the entity must provide a list of which items and services included in the dispute were not covered under the No Surprises Act and, for each item or service listed, an explanation as to why it is not covered under the No Surprises Act.
- If an entity attests that a dispute includes items or services that are covered by a coverage type not subject to the No Surprises Act, the entity must provide a list of items or services covered by the coverage type not subject to the No Surprises Act and the coverage type that applies to them.
- If an entity attests that the coverage year for an item or service in a dispute started prior to the No Surprises Act implementation date of January 1, 2022, the entity must provide: the plan or policy year associated with the dispute; and documentation to confirm the date that the plan or policy year started.
- “Not Covered by Current Insurance Policy”: If an entity attests that the dispute includes items or services not covered by the patient’s insurance policy, the entity must provide: a list of items or services in the dispute that are not covered; and documentation that confirms these items or services are not covered by the patient’s insurance policy (such as a copy of the policy).
- “Improperly Batched or Bundled”: If an entity attests that a dispute includes items or services that were improperly batched or bundled, the entity must provide a list of the items or services that were improperly batched or bundled, and for each item or service on the list, indicate the batching or bundling requirement that was not met.
- “Cooling Off Period Not Completed”: If an entity attests that a 90-calendar-day cooling off period applies to the dispute and has not been completed, the entity must provide: the dispute number for the payment determination that initiated the 90-calendar-day cooling off period; and a copy of the payment determination that initiated the 90-calendar-day cooling off period.
Categories : Uncategorized
On Monday, December 12, 2022, EDPMA sent a letter to Senator John Kennedy thanking him for introducing the Protecting Medicare Patients and Physicians Act (S.5194), which would avert two major looming reductions to Medicare provider reimbursement and creates a call to action for Congress and the Administration to pursue long-term reform of Medicare physician payment. The letter can be found here.
Categories : News
Free Members-Only Webinar: Federal Advocacy: 2022 Recap and 2023 Advocacy Watch
By arobertson
Friday,
December
9th,
2022
Join EDPMA’s experts as we look back to 2022 Federal advocacy milestones and explore how they may shape our issues in 2023.
2022 In Review: EDPMA’s Legislative & Regulatory Activities & Achievements
How may the 118th Congress impacts our issues?
What do we see in the 2023 federal legislative and regulatory horizons?
Thursday, January 12
2p – 3p EST
Faculty:
Andrea Brault, MD FACEP – EDPMA Federal Health Policy Committee Co-Chair
Randy Pilgrim, MD FACEP – EDPMA Federal Health Policy Committee Co-Chair
Judith Gorsuch, JD – Hart Health Strategies
Bob Jasak, JD – Hart Health Strategies
This free webinar is available only to EDPMA members.
Categories : Past Events
EDPMA Virtual Workshop: Facing Reimbursement Headwinds: Planning for Profitable Growth in 2023 and Beyond
By arobertson
Friday,
December
9th,
2022
With strong headwinds facing the traditional success model for EM, new strategies must be pursued to grow and remain profitable. During this workshop you will learn from successful EM group leaders how they plan for and move towards a business model less reliant on fee for service brick & mortar EM revenue. We will also review the costs & key performance indicators you’ll need to monitor as you evolve your business. Last, we will explore how relationships with staff, hospital administration, payers, and your community enable you to successfully evolve.
Learning Objectives
- Participants will learn how to plan for growth through an Enterprise Risk Framework that enables data driven strategic decision that balances opportunity with risk.
- Participants will learn about various growth opportunities and get tips on how to prioritize and pursue them
- Participants will learn about the best opportunities, methods and data needed to pursue quality Pay for Performance programs that are not only good medicine but also pay off
- Participants will learn about how to pursue, develop and maintain relationships to enable the agility needed for change and growth.
Categories : Uncategorized
EDPMA Supports TMA’s Lawsuit and the Implementation of the No Surprises Act as Intended
By arobertson
Thursday,
December
1st,
2022
McLean, Virginia – The Emergency Department Practice Management Association (EDPMA) fully supports the Texas Medical Association’s efforts to hold accountable the Department of Health and Human Services, Department of Labor and the Department of Treasury (the Departments) to ensure fair and equitable implementation of the No Surprises Act as intended. To read the full press release click here.
Categories : News
EDPMA Applauds the Ways and Means Committee Leadership for Urging Swift Action to Fix the Flawed Implementation of the No Surprises Act
By arobertson
Wednesday,
November
23rd,
2022
In a strongly worded letter, Representatives Richard Neal and Kevin Brady, the Chairman and Ranking Member of the House Ways and Means Committee, urged three cabinet secretaries to take “swift action” to fix the No Surprises Act (NSA) final rule. Read the letter here.
The letter reminded the Secretaries that the No Surprises Act intentionally detailed a dispute resolution process that required arbitrators to equally consider several factors for their decision-making process, not just the Qualifying Payment Amount as some of our members are seeing in practice.
The final rule introduced a new “double counting” test that has no basis in the statutory text, directing IDR entities to “consider whether the additional information is already accounted for in the QPA… Even though the No Surprises Act explicitly requires an IDR entity to separately consider all of the statutory factors, the final rule precludes IDR entities from giving weight to factors like patient acuity and the complexity of furnishing the item or service at issue unless providers meet the heightened burden of disproving double-counting within the QPA.”
They further called out the Departments about their slow rollout of the Advanced Explanation of Benefits provision in the NSA.
EDPMA applauds the Ways and Means Committee leadership and stands with Representatives Neal and Brady in their demand to ensure the No Surprises Act aligns with the law and to “make the law’s transparency provisions a reality for patients.”
Categories : News