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.
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.
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.
February 2, 2023
1p – 4p EST
Member Rate: $150
Non-Member Rate: $300
The agenda can be found here.
The Center for Consumer Information and Insurance Oversight (CCIIO) released new guidance in November related to several stages of the No Surprises Act’s (NSA’s) Federal Independent Dispute Resolution (IDR) process.
. . . a party seeking to initiate a payment dispute through the federal Independent Dispute Resolution (IDR) portal will be required to include certain documentation with the notice of initiation submission. Specifically, any party initiating a payment dispute must now upload the following:
Additionally, any party that enters an open negotiation start date more than 34 business days earlier than the date on which the form was completed must now upload documents to confirm that the claim is still eligible for the IDR process. The initiating party must upload at least one of the following:
An entity that does not upload the required documentation will not be able to submit the notice of IDR initiation.
EDPMA has confirmed that this requirement to upload documentation related to the QPA does not preclude providers from initiating IDR in instances where the health plan has failed to make the required disclosures. In those cases, disputing parties should include the remittance advice or other documentation where you believe the QPA should have been disclosed had the health plan met its disclosure obligations. For departmental guidance on this topic, consult the August 2022 FAQs which state:
Q20: If a plan or issuer has failed to disclose the information it is required to provide when making an initial payment or sending a notice of denial of payment, may a provider, facility, or provider of air ambulance services initiate an open negotiation period and then proceed to the Federal IDR process?
Yes. In general, providers, facilities, and providers of air ambulance services have 30 business days from the day they receive an initial payment or a notice of denial of payment from the plan or issuer regarding an item or service to initiate open negotiation with respect to that item or service, including in cases in which information required to be provided is missing. However, a plan’s or issuer’s failure to satisfy the disclosure requirements in 26 CFR 54.9816-6T(d)(1) or (2), 26 CFR 54.9816-6(d)(1), 29 CFR 2590.716-6(d)(1) or (2), and 45 CFR 149.140(d)(1) or (2) could adversely affect a provider’s, facility’s, or provider of air ambulance services’ ability to meaningfully participate in negotiations during the open negotiation period and Federal IDR process.
In these cases, when a plan or issuer fails to comply with the disclosure requirements in 26 CFR 54.9816-6T(d)(1) or (2), 26 CFR 54.9816-6(d)(1), 29 CFR 2590.716-6(d)(1) or (2), and 45 CFR 149.140(d)(1) or (2), providers, facilities, or providers of air ambulance services retain the right to initiate the open negotiation period within 30 business days of receiving the initial payment or notice of denial of payment. In initiating the open negotiation period, the provider, facility, or provider of air ambulance services, must provide the standard open negotiation notice to the plan or issuer, as required in 26 CFR 54.9816-8T(b), 29 CFR 2590.716-8(b), and 45 CFR 149.140(b). After the 30-business-day open negotiation period has lapsed, the provider, facility, or provider of air ambulance services may initiate the Federal IDR process in accordance with the normal timelines.
Alternatively, in cases in which a plan or issuer fails to comply with the disclosure requirements in 26 CFR 54.9816-6T(d)(1) or (2), 26 CFR 54.9816-6(d)(1), 29 CFR 2590.716-6(d)(1) or (2), and 45 CFR 149.140(d)(1) or (2), providers, facilities, or providers of air ambulance services may request an extension to initiate the Federal IDR process, and provide applicable attestations, by emailing a request for extension due to extenuating circumstances to FederalIDRQuestions@cms.hhs.gov, including the time period(s) for which they are seeking an extension.
Failure by either party to supply information that is required to be submitted to the certified IDR entity (for example, failure to provide the QPA) may lead to a finding by the certified IDR entity that does not take into consideration the absent information, or may lead to the certified IDR entity drawing an inference about the absent information that is adverse to that party. Providers, facilities, and providers of air ambulance services with concerns about a plan’s or issuer’s compliance with the requirements of 26 CFR 54.9816-6T(d)(1), 26 CFR 54.9816- 6(d)(1), 29 CFR 2590.716-6(d)(1), and 45 CFR 149.140(d)(1), including concerns that a plan or issuer is not acting in good faith with respect to this requirement, may contact the No Surprises Help Desk at 1-800-985-3059 or submit a complaint at https://www.cms.gov/nosurprises/policies-and-resources/providers-submit-a-billing-complaint. The Departments will generally enforce the applicable provisions of the No Surprises Act, in conjunction with states where applicable. (Footnotes omitted).
EDPMA continues its close work with ACEP on implementation and advocacy related to the No Surprises Act and will continue to provide additional updates and information.
On November 1st, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2023 Hospital Outpatient Prospective Payment System final rule. This rule also finalized policies for the new Medicare enrollment designation of Rural Emergency Hospitals (REHs), which were authorized under law to be eligible for Medicare payments beginning on January 1, 2023. Here are the key takeaways from the finalized provisions related to REHs:
On November 1st, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2023 Medicare Physician Fee Schedule (MPFS) final rule. The rule finalizes changes to the MPFS and other Medicare Part B payment policies, along with changes to the Quality Payment Program (QPP).
Here are the big takeaways for emergency medicine from the final rule:
David Schillinger, MD, FACEP
Rep. Neal Dunn (R-Fla.)
William Freudenthal, MD, FACEP
William Freudenthal, MD, FACEP
Rep. Larry Bucshon (R-Ind.)
David Schillinger, MD, FACEP
FOR IMMEDIATE RELEASE
EDPMA Files Amicus Brief Holding Federal Regulators Accountable To Implement the No Surprises Act As Required By Law
McLean, Virginia – The Emergency Department Practice Management Association (EDPMA) filed an amicus brief today in support of the Texas Medical Association (TMA), Dr. Adam Corley and Tyler Regional Hospital, LLC’s lawsuit against federal regulators challenging the implementation of the No Surprises Act (Rule) that clearly favors health plans.
Last fall, EDPMA, and the Virginia and Texas College of Emergency Physicians filed an amicus brief in support of TMA’s first lawsuit challenging federal regulators on the process to resolve reimbursement disputes between insurance plans and physicians, with special emphasis on the adverse effects the Rule threatens on the delivery of emergency care. The TMA plaintiffs won this lawsuit.
The court ruled that the NSA was not ambiguous and required that all the factors listed in the statute should be considered in determining the final payment amount. In the settled TMA case, the court clearly stated that the methodology used by health plans to calculate the QPA was incompatible with the No Surprises Act.
However, nothing really changed regarding how arbitrators resolved billing disputes between healthcare plans and physicians. In fact, arbitrators continue to unfairly skew independent dispute resolution (IDR) results in favor of insurers.
“EDPMA fully supports claims in the TMA lawsuit that simply ask that the No Surprises Act be followed as written so that the arbitrators charged with resolving payment disputes would not anchor the payment amount to the QPA and that their decision making is rooted in the statute. If the current final rule and de-facto benchmark standard goes unchecked, emergency medicine physicians, their practices and their value as our nation’s healthcare safety net are in jeopardy. Access to emergency care – which was vital to assisting our country through the pandemic – will be compromised with fewer resources to emergency care while the health plans then and now continue to post record profits,” says Don Powell, DO, FACEP, EDPMA Chair of the Board.
EDPMA will continue to advocate for emergency medicine physicians and their practices to ensure fair reimbursement to protect patients and their in-network choices.
EDPMA is the nation’s only 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 approximately half of the 146 million patients that visit U.S. emergency departments each year.
703.506.3282 (direct) l 817.905.3310 (cell)
The Centers for Medicare and Medicaid Services (CMS) recently issued two rulemaking vehicles to implement the new facility enrollment designation of Rural Emergency Hospitals (REHs) as created by Congress when it passed the Consolidated Appropriations Act, 2021. The statutory provision allows for the establishment of REHs by essentially allowing already-existing critical access hospitals (CAHs) and certain rural hospitals to convert to REHs. Eligible facilities will be able to enroll as REHs under statute for January 1, 2023 services. In preparation for the rules, EDPMA created a work group tasked with developing policies and requests for changes where needed. As a result of these efforts, EDPMA responded to both REH proposed rule comment solicitations:
You can review the full EDPMA response to the REH CoP proposed rule here.
The full EDPMA CY 2023 OPPS comment letter on these REH provisions is available here.