Archive for News

EDPMA Concerned About Health Plans’ Threats to Cut Physician Reimbursement Of Up To 50%

The Emergency Department Practice Management Association (EDPMA) is concerned about health plans’ systemic and drastic reductions in emergency medicine physician reimbursement and threats to physician group contracts under their misinterpretation of the No Surprises Act. To read the full letter click HERE.

EDPMA Joins Coalition Urging Congress to Pass CF Adjustment for 2023 and Wave PAYGO Requirement

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.

CMS Issues CY 2023 Hospital Outpatient Payment Proposed Rule; Includes Additional Rural Emergency Hospital (REH) Provisions

This afternoon, the Centers for Medicare and Medicaid Services released the calendar year (CY) 2023 Hospital Outpatient Prospective Payment System (OPPS) proposed rule.  While physician payments under the Medicare Physician Fee Schedule continue to be cut due to statutory budget neutrality provisions, CMS proposes to increase hospital outpatient payments by 2.7%. 

Also included in this proposed rule are several new provisions for Rural Emergency Hospitals (REHs). Congressionally-created in the Consolidated Appropriations Act, 2021, REH is the new enrollment designation for hospitals that “were CAHs [critical access hospitals] or rural hospitals with not more than 50 beds, participating in Medicare, as of the date of enactment” (December 27, 2020) and wish to convert to and enroll in Medicare as an REH. REHs must provide emergency and observation care. As you will recall, we recently announced a proposed rule directed at the Conditions of Participation (CoPs) for REHs.  The provisions included here in the CY 2023 OPPS proposed rule are directed at REH enrollment, payment, and quality reporting.  A CMS fact sheet on REHs is available here.  CMS notes that it will finalize the REH CoPs with the enrollment, payment, and quality reporting provisions later this Fall. 

For those interested in more details, CMS also issued a related press release and fact sheet  

EDPMA will continue to review all of the provisions of the rule and provide additional details.  EDPMA plans to file comments on the proposed rule by the September 13, 2022 deadline.

EDPMA Concerned About Systemic Denial and Delay In Payment by Payers Affecting the Delivery of Emergency Care

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


Cathey Wise
703.506.3282 (direct) l 817.905.3310 (cell)

CMS Releases CY 2023 Medicare Physician Fee Schedule Proposed Rule

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.

News Alert: EDPMA-ACEP Letter to Tri Agencies Regarding NSA Billing Compliance Issues

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!

CMS Releases No Surprises Act Checklist of Payer Requirements

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 and ACEP Meet with CMS/CCIIO Staff To Advocate For You Re: Implementation of the No Surprises Act

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:

  1. 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.
  2. 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.

EDPMA-ACEP Letter on NSA Billing Compliance Issues

On Monday, April 25, EDPMA and ACEP sent a letter to the Departments of HHS, Labor and Treasury highlighting how health plans have not supplied basic information required by the NSA when paying for patient care services. The letter can be found here.

EDPMA Letter to CMS Regarding Split/Shared Services

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.