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In this Issue...
- Congress Failing America's Medicare Patients
- $15 Billion Savings with Prior Authorization Reform
- Using Caregiver Training Services (CTS) in 2024
- Getting EMTALA Questions Answered
- Physician Vitality Program
- Information Session for Saltzer Heatlh Providers
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Become an IMA Member!
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Communication Failure and Medical Malpractice - IMA Education Webinar
- Navigating Options: Informed Decision-Making For Your Future
- Order Your 2024 AMA Coding BooksToday!
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Congress Failing America's Medicare Patients
The AMA and other medical groups urged Congress to reverse the 3.37% cut in Medicare physician payment reimbursement that took effect on Jan 1.
Congress passed a continuing resolution (CR) that funds four appropriation bills to avoid a government shutdown. The CR delayed cuts to safety-net hospitals and community health centers but did not reverse the physician pay cut. This is a disservice to Medicare patients and their doctors.
The AMA has been advocating for H. R. 6683, which aims to cancel the entire 3.37% cut, and a large group of bipartisan members of Congress are urging their leaders to pass legislation quickly to address the Medicare payment cuts. It's important to ensure that Medicare beneficiaries receive the healthcare services they need without any unnecessary interruptions or reductions.
Physicians are finding it challenging to maintain their practices and provide care to patients due to the recent Medicare physician pay cuts. The 3.37% cut, combined with the 2% cut from 2023, has made things worse. Even after adjusting for inflation, the payment rate to physicians caring for Medicare patients has decreased by 26% since 2001, which is not sustainable.
Notably, physicians represent the only group that does not automatically receive an annual inflation increase to account for the escalating costs of their business operations. Recently, the influential Medicare Payment Advisory Committee issued another recommendation to augment payment rates based on an inflation-based index for Medicare.
If physicians received an inflationary adjustment similar to hospitals and other health professionals, they could have seen a 4.6% increase in payment in 2024 if they were included in this adjustment. The AMA, IMA, and other medical associations will continue to push back against these harmful cuts and advocate for overall Medicare payment reform.
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$15 Billion Savings with Prior Authorization Reform
The Centers for Medicare and Medicaid Services (CMS) have announced a final rule, making important reforms to prior authorization to cut patient care delays and electronically streamline the process for physicians. According to the U.S. Department of Health and Human Services (HHS), physician practices will save an estimated $15 billion over 10 years with these changes.
The rule addresses prior authorization for medical services in these government-regulated health plans:
- Medicate Advantage
- State Medicaid and Children's Health Insurance Program (CHIP) fee-for-service programs
- Medicaid managed care plans and CHIP managed care entities
- Qualified health plan issuers on the federally facilitated exchanges
While they continue to analyze the details of the final rule, their initial read suggests that CMS has taken important steps toward right-sizing the PA process by addressing both technological and operational requirements. Among the technology provisions is a requirement that impacted payers support an electronic PA process that is embedded within physicians’ electronic health records (EHR)—bringing much-needed automation and efficiency to the current time-consuming, manual workflow. In addition, CMS is curtailing payers’ PA processes by mandating shortened PA processing timeframes and significantly enhancing transparency around PA, including requirements for specific denial reasons and public reporting of program metrics. CMS also requires that payers provide physicians and patients with more PA-related information.
CMS received feedback on the effective date of its policies, including technology challenges, and noted that enforcement of policies, particularly around Medicare Advantage payers, can include CMS sanctions and civil monetary penalties. Unless otherwise noted in the summaries linked below the article, CMS’ policies will go into effect January 1, 2027.
AMA Steps Up
Although payers argue that prior authorization requirements are implemented to control costs and maintain quality, a significant proportion of physicians report that these protocols result in unnecessary waste and harm to patients that could have been avoided. In a survey conducted by American Medical Association (AMA), one-third of the 1,001 physicians who participated reported that prior authorization led to a serious adverse event for a patient under their care.
The AMA survey found that a significant percentage of physicians reported that prior authorization resulted in:
- A patient’s hospitalization—25%
- A life-threatening event or one that required intervention to prevent permanent impairment or damage—19%
- A patient’s disability or permanent bodily damage, congenital anomaly or birth defect, or death—9%
In addition to the survey, AMA released a press statement commending the Biden Administration's PA reforms, which prioritize patients' access to care and alleviate administrative burdens for physicians and their staff. By focusing on patient care and reducing administrative complexities, reforms are expected to improve the quality of healthcare services across the country, including here in Idaho.
a whole.
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Using Caregiver Training Services (CTS) in 2024
By Jana Weis, Gill Compliance Solutions
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As mentioned in the IMA Final Rule webinar in November, CMS will start paying for two existing CPT codes, allowing physicians and qualified healthcare professionals to provide training for caregivers of patients. Code 96202 is an initial training visit defined as multiple-family group behavior management/ modification training for parent(s)/guardian(s)/ caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/ caregiver(s); initial 60 minutes. CMS provided examples in the Final Rule to include, but not limited to stroke, traumatic brain injury, various forms of dementia, autism spectrum disorders, individuals with other intellectual or cognitive disabilities, physical mobility limitations, or necessary use of assisted devices or mobility aids. Note: the patient does not have to be present to provide this service. Verbal or written consent in required by the patient. Add-on CPT code +96203 could also be used for each 15 increment over the initial hour.
A second set of codes, addressing caregivers needing more functional performance or ADL training have also approved for CMS payment. These are considered ‘sometimes therapy services’ and can be performed and billed by physical, occupational, and/or speech therapists. Codes include:
97550 - Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face-to-face; initial 30 minutes), and +97551 - each additional 15 minutes, and 97552 - group caregiver training.
CMS commented that the patient situation and medical necessity should drive the frequency of these visits. Yet, they did not discuss whether CTS codes would be considered appropriate for telehealth in future years.
Please see the table below with Q1 2024 Noridian Reimbursement.
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Getting EMTALA Questions Answered
By Kim Stanger and Cameron McCue, Holland & Hart LLP
Question: Can abortions be performed in Idaho in EMTALA cases?
Answer: Probably not, unless the procedure is necessary to preserve the life of the mother or in cases of rape and incest if specific conditions are met.
Last year, the District Court of Idaho ruled that the Emergency Treatment and Active Labor Act (“EMTALA”) likely preempted Idaho’s total abortion ban and issued a temporary injunction prohibiting enforcement of the abortion ban in cases subject to EMTALA. After “on-again-off-again” proceedings at the 9th Circuit, the United States Supreme Court agreed to hear the case. Oral arguments are scheduled for April of this year, with a final ruling potentially not arriving until later in the summer. In the meantime, the Supreme Court has effectively terminated the temporary injunction, thereby allowing Idaho to enforce the total abortion ban even in EMTALA cases.
This is designed to provide general information on pertinent legal topics. The statements made are provided for educational purposes only. They do not constitute legal advice nor do they necessarily reflect the views of Holland & Hart LLP or any of its attorneys other than the author.
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Physician Vitality Program | | |
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The Physician Vitality Program (PVP) offers confidential, affordable, and easily accessible mental health support tailored for Idaho's physicians. It is now available to all medical licensed professionals (physicians, PAs, NPs) who are members of the IMA wherever they practice. PVP was created by Ada County Medical Society in 2016 to address the growing needs of those facing the epidemic of physician burnout, as well as other occupational and personal stressors | |
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The program provides five confidential appointments at no cost, with a strong emphasis on maintaining the privacy of individuals seeking help. While many clinicians have access to Employee Assistance Programs (EAPs) through their insurance plans, they often hesitate to use them due to genuine or perceived confidentiality concerns. ACMS created its own panel of clinically licensed mental health professionals available throughout Idaho and via telehealth and chose those with a reputation for serving medical clinicians. It is suitable for those seeking help for depression, grief, relationship and work challenges, imposter syndrome, and other issues commonly faced by those who practice medicine.
To determine if you are eligible for services, you may verify your IMA membership at https://www.idmed.org/idaho/Idaho_Public/Physician_Finder/Idaho_Public/Physician_Finder/Search.aspx.
To find out more about this program and access appointments, visit the site by clicking the button below.
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MIEC will be hosting an exclusive information session for Saltzer Health physicians and allied staff at Coiled Winery & Tasting Room, Thursday February 8th from 5:00pm to 7:00 pm.
Discussions will include exclusive MIEC malpractice insurance programs for Saltzer Health providers evaluating transition, and additional community resources will be in attendance to provide support and answer questions regarding independent practice. For full event details, please visit https://www.miec.com/cme/events or RSVP and register below.
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Become an IMA Member!
Idaho Medical Association (IMA) is the leading organization representing physicians in all specialties, practice settings, and geographic locations in our state, and is recognized as the voice of medicine in Idaho. IMA’s mission is to unify and advocate for all Idaho physicians, promote the art and science of medicine, and remain dedicated to improving the health and well-being of all Idahoans.
Idaho Medical Association has over 4,000 members, all Idaho medical professionals who meet the Association's stringent membership requirements. Predominant membership is comprised of over 2,000 actively practicing physicians, including residents, with the balance of members comprised of retired physicians, physician assistants, nurse practitioners, and medical students.
* Don't forget: If you pay your AMA dues through IMA, IMA benefits.
You can easily join IMA by visiting www.idmed.org or contacting us at (208) 334-7888.
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Order Your 2024 ICD-10-CM Complete Official Code Set Today!
The newest codes in the ICD-10 book took effect October 1 and your billing staff will need to start using these new codes ASAP! The books are already at the IMA office and can be picked up, shipped, or delivered today! The 2024 ICD-10-CM files contain information on the ICD-10-CM updates for FY 2024. These 2024 ICD-10-CM codes are to be used for discharges from October 1, 2023, through September 30, 2024, and for patient encounters from October 1, 2023, through September 30, 2024.
As part of your membership, Idaho Medical Association offers most coding, billing, and reference manuals at a significant discount. This saves you and your office money when you provide your staff with the tools to help you ward off unwelcome challenges to your revenue. The order form for 2024 publications is available here. If you have questions or if there is a type of book you don’t see, but would like to purchase, please contact Rebecca Adams at rebecca@idmed.org or 208-344-7888 ext. 101.
CPT ® is a registered trademark of the American Medical Association
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