News & Press

CY 2027 Medicare Advantage final rule: What physicians need to know

Mon, 13 Apr 2026 13:40:00 GMT

Medicare Advantage Final Rule: Key Changes Physicians Should Know

The American Medical Association (AMA) released an April 10 advocacy update outlining the CY 2027 Medicare Advantage final rule and its implications for physicians.

Key highlights include:

More accurate risk score calculations through the exclusion of unlinked chart review records
New continuity-of-care protections for certain Medicare Advantage enrollees
A 2.48% average payment increase for plans

The update also notes ongoing concerns:

Reduced oversight and accountability for Medicare Advantage plans
Changes to prior authorization and utilization management requirements
Continuing administrative challenges for physicians

Moratorium on Enrollment of New Durable Medical Equipment, Prosthetics, Orthotics, and Suppliers

Thu, 26 Mar 2026 14:50:00 GMT

Florida Medicaid Health Care Alert

March 25, 2026

Provider Type(s):ALL

Moratorium on Enrollment of New Durable Medical Equipment, Prosthetics, Orthotics, and Suppliers

On February 27, 2026, The Centers for Medicare & Medicaid Services (CMS) imposed a 6-month nationwide moratorium on the Medicare enrollment of New Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) medical supply companies. A copy of the moratorium can be found here.

The goal of the temporary moratorium is to fight fraud and safeguard taxpayer dollars, while ensuring patient access to care. Authority to impose such moratoria was included in the Affordable Care Act, and the Agency for Health Care Administration (Agency), with the approval from CMS, is exercising that authority at this time.

Effective March 20, 2026, the Agency has imposed a temporary Medicaid moratorium on enrollment of new Durable Medical Equipment DME providers (Provider Type 90) in all Florida counties.

Exclusively for purposes of the moratorium's applicability, a medical supply company is considered a business whose principal function is to furnish durable medical equipment and medical supplies (regardless of supply type) directly to another party, such as, but not limited to: (1) recipients with a medical order (for example, via mail order); (2) medical providers and suppliers; or (3) both. A pharmacy, hospital, or other medical provider that also provide DME as a secondary function are not part of this moratorium.

The statewide moratorium will remain in place for an initial 6-month period. Under the moratorium, the Agency will not accept any new applications for DME providers for Florida Medicaid enrollment that are received after March 20, 2026. The Agency will continue processing DME provider applications submitted on or before March 20, 2026.

No Medicaid recipients will go without the services they need. If any recipient is having difficulty accessing services, please encourage them to contact the Florida Medicaid Helpline at (877) 254-1055.

All existing DME providers can continue to deliver and bill for authorized services.

QUESTIONS? FLMedicaidManagedCare@ahca.myflorida.com

COMPLAINTS OR ISSUES? ON LINE ahca.myflorida.com/Medicaid/complaints/ | CALL 1-877-254-1055

The Agency for Health Care Administration is committed to its mission of providing "Better Health Care for All Floridians." The Agency administers Florida’s Medicaid program, licenses and regulates more than 48,000 health care facilities and 47 health maintenance organizations, and publishes health care data and statistics at FloridaHealthFinder.gov. Additional information about Agency initiatives is available via Facebook (AHCAFlorida) and Twitter (@AHCA_FL)

Short-term extension of key Medicare policies

Tue, 18 Nov 2025 14:05:00 GMT

Congress ends longest congressional shutdown and includes short-term extension of key Medicare policies (Source: AMA)

After more than 40 days, the longest shutdown of the federal government caused by a lapse in appropriations funding ended on Nov. 12 following congressional passage of H.R. 5371, the Continuing Appropriations and Extensions Act, 2026. Despite the prolonged federal shutdown, H.R. 5371 only fully funds the Department of Agriculture, Department of Veterans Affairs, Department of Defense’s Military Construction activities, and legislative branch for the entirety of the 2026 fiscal year, which ends on Oct. 1, 2026. The Food and Drug Administration (FDA) received full funding due to its inclusion in the Department of Agriculture appropriations bill. Congress, however, only allocated funding for the remainder of the federal government, including the Department of Health and Human Services, through Jan. 30, 2026.

H.R. 5371 does include temporary extensions of numerous AMA-supported provisions that expired on Oct. 1 due to the inability of Congress to pass compromise legislation. More specifically, all existing telehealth flexibilities (i.e., suspension of the statutory geographic and originating site restrictions originally enacted during the COVID-19 public health emergency), the hospital-at-home waiver, and 1.0 work geographic practice cost index (GPCI) floor were extended through Jan. 30. In addition, the Community Health Center Fund, National Health Service Corps (NHSC), Teaching Health Center Graduate Medical Education Program (THCGME), as well as the Special Diabetes Program for Type I Diabetes and Native Americans, was also extended until the end of January 2026. The new Jan. 30 deadline also extends the moratorium on data reporting requirements and associated payment cuts to the Clinical Laboratory Fee Schedule that were initially implemented following passage of the Protecting Access to Medicare Act (PAMA) of 2014.

Finally, Congress included provisions to waive “Statutory Pay-As-You-Go (PAYGO)” requirements that were triggered following passage of H.R. 1, the One Big Beautiful Bill Act, in July 2025. Under the Statutory PAYGO Act of 2010, if a law increases the deficit over a five or ten-year period, a mandatory sequester, or an across-the-board-cut, is triggered. The Office of Management and Budget (OMB) tracks the budgetary effects of all laws passed by Congress during a specific legislative session on two scorecards. While Congress has never permitted these cuts going into effect, Medicare, as well as numerous other federal programs, are affected by Statutory PAYGO cuts. Absent congressional intervention, Medicare was slated for an approximately $530 billion cut associated with the long-term fiscal impact of previously passed bills, including the One Big Beautiful Bill Act. Section 8001 of H.R. 5371 directs OMB to clear the scorecards and eliminates any potential associated sequester cuts, including in Medicare.

The compromise legislation did not include any extension of the Affordable Care Act (ACA) Enhanced Premium Tax Credits (EPTCs) that are still slated to expire at the end of 2025. In September, the AMA and many other state and national medical specialty societies sent a bipartisan, bicameral letter (PDF) pressuring congressional leadership to extend the tax credits before the end of 2025. While bipartisan members of the Senate pledge to hold a vote on a potential extension of the ACA EPTCs in December in exchange for passage of H.R. 5371, the House of Representatives has not offered a similar commitment, to date. AMA will continue to closely monitor the ongoing congressional debate surrounding the ACA EPTCs and federal funding.

Medicaid advocates raise concern over prior authorization denials in managed care plans

Wed, 26 Jul 2023 17:38:00 GMT

Bloomberg Law (7/25, Belloni, Subscription Publication) reports, “Medicaid advocates are sounding the alarm over systemic oversight failures and misaligned incentives that allow Medicaid managed care companies to restrict patient access to health care services.” The Department of Health and Human Services Office of Inspector General “ found that 37 states it surveyed had systemic problems with their prior authorization processes, leading to inappropriate denials of coverage.” Among the issues were failing to let Medicaid patients know about “their right to appeal a denial, allowing insufficiently trained staff to make prior authorization decisions, and writing notices in ambiguous, often hard-to-understand language that missed or concealed important information such as the reason for a rejection.”

Below is the Florida specific denial rates for the Medicaid Managed Care Plans according the DHS OIG Study. In Florida, Medicaid Beneficiaries are auto assigned to a Managed Care Company in their region. Evidently for Medicaid Beneficiaries, their assignment becomes a lottery as to their likelihood of getting the care they need.

Parent Company	MCO Name	State	2019 Average Enrollment	2019 Prior Authorization Denial Rate
Aetna	Aetna Better Health of Florida	FL	85,411	10.10%
AmeriHealth Caritas	Prestige Health Choice	FL	77,182	10.40%
Anthem	Simply HealthCare Plans, Inc.	FL	457,851	10.50%
Centene	Sunshine State Health Plan	FL	533,398	13.60%
Centene	Wellcare of Florida, Inc.	FL	764,156	9.30%
Molina	Molina Healthcare of Florida Inc.	FL	95,207	16.60%
United Healthcare	UHC Community Plan of FL	FL	238,926	21.90%

The final countdown to Medicare physician payment cuts has begun!

Tue, 6 Dec 2022 14:19:00 GMT

We've been sounding the alarm bell for months that if Congress didn't act by the end of the year, physicians would face devastating Medicare payment cuts from regulatory changes enacted by the Centers for Medicare and Medicaid Services. Unfortunately, as you can see by the countdown timer above, Congress has only a few precious days left to pass legislation to stave off these harmful cuts.

It's now or never – Tell Congress to protect America's Medicare patients and stop the cuts!

If Congress fails to act, physician Medicare payments are scheduled to be cut by 4.5 percent on January 1,2023.Cuts of this magnitude would severely impede patient access to care by forcing many physician practices to close and thereby putting further strain on those that remained open during the pandemic.

These scheduled cuts will come in the form of:

Centers for Medicare & Medicaid Services (CMS) regulation. CMS has proposed a 4.5% cut for all physician services in 2023 to offset payment policy improvements in office and facility-based visits.
No inflationary update. Physicians are the only providers whose Medicare payments do not automatically receive an annual inflationary update; during this time of record inflation and coming on the heels of a highly disruptive pandemic, this statutory flaw amplifies the impact of proposed payment cuts.

When adjusted for inflation, Medicare physician payments have dropped by 22% from 2001 to 2021. Physicians simply cannot afford to operate under the current payment system. Congress must reform the Medicare physician payment system to make it simpler, more reflective of real-world physician practice costs and stable for both physicians and patients before it's too late!

The "lame duck" session of Congress is always a chaotic time with numerous priorities and interests vying to be included in the final must-pass package. With so much at stake, America's patients and physicians cannot afford to get lost in the shuffle.

Time is running out - Contact Congress NOW and demand that they protect our patients and practices by canceling these devastating Medicare cuts in their entirety before the clock strikes zero!

CMS Releases 2023 Medicare fee Schedule Final Rule

Thu, 17 Nov 2022 18:29:00 GMT

2023 Medicare Fee Schedule

The final rule for the 2023 Medicare Fee Schedule was released on November 1, and there was little changed from what was outlined in July’s proposed rule.

Issues addressed include:
• the 2023 conversion factor
• split/shared services
• and documentation of inpatient E&M services

The payment cut that should be on every physician’s radar

Mon, 31 Oct 2022 13:49:00 GMT

Many physicians in Florida — even those who do not participate in the Medicare fee-for-service program — stand to be affected by an 8.42% Medicare physician payment cut that will take effect in 2023 unless Congress intervenes. As explained in a recent FMA update , “Since commercial payment rates are generally a function of Medicare rates, any reduction in the value of Medicare payments will also likely spill over to the commercial rates paid to many physician practices.”

You can support our efforts to prevent this egregious payment cut by sending a pre-written, customizable letter to your Congress members. Read our update for details about the potential impact on Florida’s Medicare beneficiaries and physicians.

Click here to submit your letter now.

Amid providers’ push . . . Becerra Hopes To Work With Congress To Reform Medicare Doc Pay

Fri, 18 Mar 2022 17:56:00 GMT

By Michelle M. Stein / March 17, 2022 at 7:13 PM

https://insidehealthpolicy.com/daily-news/becerra-hopes-work-congress-reform-medicare-doc-pay

HHS Secretary Xavier Becerra indicated he hopes to work with Congress on changes to the Medicare physician fee schedule, coming as providers tell lawmakers the agency’s planned pay freeze for fee-for-service Medicare can’t be reconciled with the projected almost 8% pay raise for Medicare Advantage.

Becerra also said at a meeting with reporters on Thursday (March 17) that HHS will step up its oversight of Medicare Advantage and suggest to Congress any reforms that would increase the Medicare program’s value to beneficiaries. He acknowledged concerns about overpayments in MA and potential upcoding, and said HHS is looking closely at some aspects of the MA pay system.

“We are looking closer into some aspects of the payment system in Medicare Advantage, and we want to make sure that, again, whether it’s fee for service or Medicare Advantage, that seniors are getting value for their previous contributions and taxes,” Becerra said.

Providers and some lawmakers have pushed for months to get Congress to look at long-term Medicare pay reforms. Some GOP lawmakers pushed for reforms and hearings during House discussion of Democrats’ now-defunct Build Back Better package last fall, while others pushed for an in-depth look at the system prior to the passage of stop-gap fixes to Medicare pay in December.

As it stands, Medicare sequester cuts are set to begin phasing in on April 1 with a 1% cut that grows to 2% come July. Further sequester cuts are set to go into effect late this year or early next year as a result of the cost of the American Rescue Plan, according to the Committee for a Responsible Federal Budget, after lawmakers moved the cost of that law to the 2023 PAY-GO scorecard last December.

Providers are lobbying hard to stop the pay cuts. Some providers also are pressing lawmakers to stop the phase-in of cuts tied to CMS changes to clinical labor policy in the physician fee schedule, while others are worried about the end of the alternative payment model bonuses coming next year.

The Medicare Payment Advisory Commission’s recent recommendation backing a pay freeze for physicians under the fee schedule has also caused consternation among providers, with the American Medical Association saying such a move would hurt patient access.

“Physicians have been enduring an increasing financial instability of the Medicare physician payment system due to a confluence of fiscal uncertainties related to the COVID-19 pandemic, statutory payment cuts, consistent lack of inflationary updates, and significant administrative barriers,” AMA says in a March 15 letter to House and Senate leadership. “Freezing physician payment is also impossible to reconcile when viewed against the nearly eight percent payment increase the Centers for Medicare & Medicaid Services projects for Medicare Advantage plans in 2023.”

AMA alleges that providers under the physician fee schedule lack an annual pay update on par with other providers in Medicare and per-enrollee spending under the fee schedule has fallen, even as other providers are seeing an increase in Medicare pay. AMA says the group is grateful that Congress acted to avert a nearly 10% cut to physician pay in 2022, but Congress needs to do more.

“[I]t is urgent that Congress work with the physician community to develop solutions to the systematic problems with the Medicare physician payment system and preserve patient access to care. At a minimum, Congress must establish a stable, annual Medicare physician payment update that keeps pace with inflation and practice costs and allows for innovation to ensure Medicare patients continue to have access to physician practice-based care,” AMA says.

A coalition of organizations representing more than a million providers also told key committee leaders late last month that the physician fee schedule’s budget-neutrality requirements and the lack of an annual inflationary update will continue to generate significant instability for providers. They raised problems with the Merit-based Incentive Payment System, as well. The incentive payments in MIPS have been far below what Congress envisioned when the Medicare Access and CHIP Reauthorization Act was passed, and those low incentives combined with what the group calls instability in the physician fee schedule have caused some providers to see pay decline even as costs increase, the coalition says in a Feb. 25 letter.

Becerra on Thursday was asked about providers’ push for reform of the physician fee schedule and whether HHS is interested in talking about that with Congress.

“I’m definitely interested because I remember those cliffs from when I was in Congress. We always have to deal with those,” Becerra said, referring to the Congress’ repeated patches to the Sustainable Growth Rate formula, which was replaced by MACRA.

“And now that we’ve seen what happens when you got COVID, and how important the health profession is, you never want folks thinking there may be a different profession for them down the line because they’re just not making it where they are,” he added.

One lobbyist said it is possible that lawmakers could hold hearings on Medicare pay issues later this year, but another predicted Medicare physician pay reforms are unlikely to be a high priority.

A spokesperson for the House Energy & Commerce Committee said the committee is “always interested in ways to improve beneficiary access to quality care in Medicare,” but did not provide additional details. The House Ways & Means chair and ranking Republican at press time had not responded to questions on whether they plan to consider Medicare pay reforms, and the Senate Finance Committee had not responded to similar questions. -- Michelle M. Stein ( mstein@iwpnews.com)

RPA Opposes Proposed CMS Changes to Split/Shared Services Policy Affecting MDM

Fri, 18 Feb 2022 15:52:42 GMT

As part of the rulemaking cycle for the 2022 Medicare Fee Schedule (MFS), CMS included in its July 2021 proposed rule policy changes affecting split/shared visits (described below).

Among these was a proposal that would redefine the “substantive portion” of a shared visit as more than half of the total time spent by the physician and the advanced practitioner performing the visit, regardless of medical decision making (MDM).

RPA adamantly opposed implementation of this provision in our comments on the proposed rule, and in the 2022 final rule (released in November 2021) CMS delayed implementation of the revised definition until 2023.

Read More

Provider Requirements Under the No Surprises Act Special ODF

Tue, 7 Dec 2021 13:41:03 GMT

MLN Connects® -- Special Edition - Monday, December 6, 2021

Source: First Coast Service Options Inc.

Provider Requirements Under the No Surprises Act Special ODF — December 8

Wednesday, December 8 from 2 – 3 pm ET

CMS will host a Special Open Door Forum (SODF) to explain provider requirements under the No Surprises Act. Starting January 1, 2022,consumers will have new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. These requirements generally apply to items and services provided to people enrolled in group health plans, group or individual health insurance coverage, Federal Employees Health Benefits plans, and the uninsured.

These requirements don’t apply to people with coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE that have other protections against high medical bills.

This SODF will include:

· Background and purpose

· Requirements for providers, facilities, and providers of air ambulance services starting January 1

· Enforcement provisions

· Resources and definitions

· Q&A session

How to Participate:

· Dial: 1-888-455-1397; conference ID # 8604468

· TTY services: Dial 7-1-1 or 800-855-2880

More Information:

· Presentation

· Provider Requirements and Resources webpage

· Questions: provider_enforcement@cms.hhs.gov

CMS to Apply MIPS Automatic Extreme and Uncontrollable Circumstances Policy

Thu, 11 Nov 2021 18:09:19 GMT

CMS to Apply MIPS Automatic Extreme and Uncontrollable Circumstances Policy for the 2021 Performance Year in Response to COVID-19 Public Health Emergency

Due to ongoing discussions and advocacy the AMA has being having with CMS on the impact the COVID-19-PHE is having on physician practices, CMS will apply the Automatic Extreme and Uncontrollable Circumstances Exemption Policy (EUC) for the 2021 MIPS performance year. This 2021 policy change recognizes the continued challenges physicians face with providing care during the PHE and reduces administrative burden. Therefore, if a physician participates in MIPS as an individual, they don’t need to take any action to have the automatic EUC policy applied to them. CMS will automatically identify and re-weight all 4 MIPS performance categories reweighted to 0% and receive a neutral payment adjustment for the 2023 MIPS payment year unless the physician 1) submit data in 2 or more performance categories, or 2) have a higher final score from group or APM Entity participation.

Unfortunately, due to a systems issue if a physician or small practice participates in the 2021 MIPS program by submitting Part B quality measures through claims and has submitted quality data codes on their 2021 Medicare claims, they will need to still file a 2021 MIPS Hardship EUC to avoid a 2023 payment adjustment and be exempt from the 2021 MIPS program.

If a group practice that typically participates in MIPS as a group has not submitted 2021 data, then the automatic EUC policy will apply to the individual physicians within the group. If the group has submitted any 2021 data, then they will need to apply for the EUC to avoid a 2023 payment adjustment.

Essentially, if the physician or practice has not submitted any 2021 MIPS performance data, then the automatic EUC will apply to the physician.

PY2021 EUC Exception Applications can be submitted by signing in to qpp.cms.gov and clicking Exception Applications on the left-hand navigation.

For more detailed information on the automatic EUC policy and CMS announcement, please see email below.

Source: AMA

CMS to Apply MIPS Automatic Extreme and Uncontrollable Circumstances Policy for the 2021 Performance Year in Response to COVID-19 Public Health Emergency

The Centers for Medicare & Medicaid Services (CMS) continues to provide relief where possible to clinicians responding to the 2019 Coronavirus (COVID-19) public health emergency (PHE). We’re applying the Merit-based Incentive Payment System (MIPS) automatic extreme and uncontrollable circumstances (EUC) policy to ALL individually eligible MIPS eligible clinicians for the 2021 performance year (PY). Please note that this announcement is for PY2021 only.

The automatic EUC policy only applies to MIPS eligible clinicians who are eligible to participate in MIPS as individuals. The automatic EUC policy doesn’t apply to groups, virtual groups, or Alternative Payment Model (APM) Entities.

Learn what this means for you below.

MIPS eligible clinicians who are eligible to participate in MIPS as individuals

You don’t need to take any action to have the automatic EUC policy applied to you. You’ll be automatically identified and will have all 4 MIPS performance categories reweighted to 0% and receive a neutral payment adjustment for the 2023 MIPS payment year unless you 1) submit data in 2 or more performance categories, or 2) have a higher final score from group or APM Entity participation.

Small practices reporting Medicare Part B claims measures

Under current policies, we automatically calculate a quality score from Medicare Part B claims measures at the individual and group level.

Clinicians in small practices that report Medicare Part B claims measures who are only eligible to participate in MIPS as part of a group aren’t covered by the automatic EUC policy and will receive the group’s final score. (To identify these clinicians, sign in to qpp.cms.gov, navigate to the “Eligibility & Reporting” page and click “View Clinician Eligibility”. Clinicians who are only eligible to participate as part of a group will have a green check mark next to “Group”; there won’t be a green check mark next to “Individual”.)
Some small practices may not be aware of the implications of their PY 2021 claims reporting due to some of the policies we introduced at the onset of the COVID-19 PHE.
As a result, these small practices may wish to request performance category reweighting on behalf of the group through the PY2021 EUC Exception Application, citing COVID-19 as the triggering event.
PY2021 EUC Exception Applications can be submitted by signing in to qpp.cms.gov and clicking Exception Applications on the left-hand navigation.

Groups

The automatic EUC policy doesn’t apply to groups. You don’t need to take any further action if you’re not able to submit data for the 2021 performance year. Group participation is optional (specific guidance for small practices noted above), and your individually eligible MIPS eligible clinicians qualify for the automatic EUC policy if you don’t report at the group-level on their behalf. (If you submit data at the group level on behalf of your MIPS eligible clinicians, the group will receive a MIPS final score based on the data submitted.) Your MIPS eligible clinicians will have all 4 performance categories reweighted to 0% and receive a neutral payment adjustment for the 2023 MIPS payment year unless 1) they submit data in 2 or more performance categories, or 2) they have a higher final score from group or APM Entity participation.

Virtual Groups

MIPS eligible clinicians in a virtual group will receive a payment adjustment based on the virtual group’s final score, even if no data is submitted. (When no data is submitted for the virtual group, the MIPS eligible clinicians in the virtual group could receive the maximum negative payment adjustment of -9% in the 2023 payment year.)

If you’re unable to submit data for the 2021 performance year as a result of the ongoing COVID-19 PHE, you can submit a PY2021 EUC Exception Application on behalf of the virtual group, citing COVID-19, to request reweighting for all 4 performance categories.
PY2021 EUC Exception Applications can be submitted by signing in to qpp.cms.gov and clicking Exception Applications on the left-hand navigation through December 31, 2021.

APM Entities

The automatic EUC policy doesn’t apply to APM Entities. You don’t need to take any action if you’re not able to submit data for the 2021 performance year. APM Entity participation is optional (specific guidance for small practices noted above), and your individually eligible MIPS eligible clinicians will have the automatic EUC policy applied to them if you don’t report at the APM-Entity level on their behalf. (If you submit data at the APM-Entity level on behalf of your MIPS eligible clinicians, the APM Entity will receive a MIPS final score based on data submitted.) Your MIPS eligible clinicians will have all 4 performance categories reweighted to 0% and receive a neutral payment adjustment for the 2023 MIPS payment year unless 1) they submit data in 2 or more performance categories, or 2) they have a higher final score from group or APM Entity participation.

If your APM Entity would like to request performance category reweighting for the 2021 performance year, you must submit an EUC application.

PY2021 EUC Exception Applications can be submitted by signing in to qpp.cms.gov and clicking Exception Applications on the left-hand navigation through December 31, 2021.

Medicare Shared Savings Program ACOs

The MIPS Automatic EUC policy doesn’t apply to Shared Savings Program Accountable Care Organizations (ACOs). ACOs can submit a PY2021 EUC Exception Application on behalf of its MIPS eligible clinicians if they are unable to report via the Alternative Payment Model (APM) Performance Pathway (APP). To submit a PY2021 EUC Exception Application, ACOs must demonstrate that greater than 75% of its MIPS eligible clinicians would be eligible for reweighting the Promoting Interoperability performance category. ACOs can submit PY2021 EUC Exception Applications by signing in to qpp.cms.gov and clicking Exception Applications on the left-hand navigation through December 31, 2021.

Note: The Shared Savings Program Quality EUC policy for determining shared savings and losses applies to all Shared Savings Program ACOs for performance year 2021. CMS considers all ACOs to be affected by the COVID-19 PHE and the Shared Savings Program EUC policy applies for PY2021. ACOs that are able to report quality data via the APP and meet MIPS data completeness and case minimum requirements will receive the higher of their ACO quality score or the 30th percentile MIPS quality performance category score. ACOs that are unable to report quality data via the APP and meet the MIPS quality data completeness and case minimum requirements, will have their quality score set equal to the 30th percentile MIPS quality performance category score.

Additional Resources

For more information, please see the Quality Payment Program COVID-19 Response webpage on the QPP website. You can contact the Quality Payment program at 1-866-288-8292 (TRS: 711), Monday through Friday, 8AM-8PM ET or by e-mail at: QPP@cms.hhs.gov.

Disclaimer: The contents of this listserv do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This listserv is intended only to provide clarity to the public regarding existing policies under the law.

Source: AMA

COVID-19 Health Care Staff Vaccination IFC-6: Presentation Slides and Video

Wed, 10 Nov 2021 17:15:57 GMT

COVID-19 Health Care Staff Vaccination IFC-6: Presentation Slides and Video

Thank you for your interest in in the COVID-19 Omnibus Vaccine Rule (IFC-6).Yesterday’s stakeholder call had a limit of 10,000 participants and we exceeded that number.Please accept our apologies.

CMS has posted the presentation slides and a recording of the stakeholder call for your convenience.

To view the slides, visit: https://www.cms.gov/files/document/covid-19-health-care-staff-vaccination-ifc-6-national-stakeholder-call-slides.pdf

To view the video, visit: https://www.youtube.com/watch?v=xHA0zY1aC-Y

In addition to the resources above, CMS has prepared a frequently asked questions document, available here: https://www.cms.gov/files/document/cms-omnibus-staff-vax-requirements-2021.pdf

Our next stakeholder call will be held on:

Wednesday, November 10

3:30 – 4:30 PM EST

To register in advance, visit:

https://cms.zoomgov.com/webinar/register/WN_bCsmBuXfTnOCK0owoQVHvg

After registering, you will receive a confirmation email containing information about joining the webinar.

*Please note we can only accommodate 10,000 participants so register early to guarantee your participation.*

Again, thank you for your interest in this important topic. We look forward to working with you and, appreciate your commitment to the safety of your staff and patients.

You're getting this message because you subscribed to get email updates from the Centers for Medicare & Medicaid Services (CMS).

Update your subscriptions, modify your password or email address, or stop subscriptions at any time on your Subscriber Preferences Page. You will need to use your email address to log in. If you have questions or problems with the subscription service, please contact subscriberhelp.govdelivery.com.

This service is provided to you at no charge by Centers for Medicare & Medicaid Services (CMS).

State levies $950K in liquidated damages against Medicaid managed care plans

Tue, 5 Oct 2021 15:58:12 GMT

Simply Healthcare was fined $422,250 in liquidated damages for the first quarter, more than any other health plan.

Florida health officials assessed $949,250 in liquidated damages in the first quarter of fiscal year 2021-2022, issuing final orders in 36 complaints against Medicaid managed care plans, Agency for Health Care Administration information shows.

Simply Healthcare was fined $422,250 in liquidated damages for the first quarter, more than any other health plan, and was responsible for about 44% of the overall amount of damages assessed in the three-month time frame. The damages were assessed in state-issued final orders settling four complaints.

While Simply Healthcare leads the Medicaid managed care plan pack in terms of the amount of liquidated damages assessed, Humana Medical Plan had seven final orders issued for the quarter, more than any other plan.

The state issued the orders between July 1 and Sept. 30 for Humana Medical Plan and levied $258,000 in liquidated damages against the health plan. Humana offers “comprehensive” health plans to Medicaid managed care enrollees throughout the state.

Staywell Health Plan had two final orders for the quarter and was levied $40,000 in liquidated damages. The managed care plan was acquired last year by Centene Corporation. Medicaid enrollment reports show that as of Aug. 31 Staywell had 23.5% of the Medicaid managed medical assistance market share.

Centene is the parent company of Sunshine Health, which offers a Medicaid managed medical assistance contract statewide and claimed 15.8% of the managed medical assistance market share in August, enrollment reports show. Regulators levied $80,000 in liquidated damages against Sunshine Health Plan for two complaints involving contract violations.

DentaQuest, a statewide Medicaid managed dental plan, had two complaints settled with final orders during the first quarter and had $3,500 in liquidated damages levied against it.

Florida contracts with Medicaid managed care plans to deliver health care services to enrollees in 11 Medicaid Regions across the state.

Source: https://floridapolitics.com/archives/462256-state-levies-950k-in-liquidated-damages-against-medicaid-managed-care-plans/

Fee-For-Service Claims

Mon, 27 Sep 2021 13:41:05 GMT

Effective 10-1-21 Fee-For-Service Claims will be Denied if Referring, Ordering, Prescribing, and Attending Providers are Not Enrolled

Florida Medicaid Health Care Alert: September 23, 2021

Provider Type(s): All

Final Reminder: Effective 10-1-21 Fee-For-Service Claims will be Denied if Referring, Ordering, Prescribing, and Attending Providers are Not Enrolled

Effective October 1, 2021, any fee-for-service (FFS) claim submitted with a National Provider Identifier (NPI) for a provider not enrolled with Florida Medicaid will be denied, and the provider will not receive reimbursement for services. This includes claims that list a Referring, Ordering, Prescribing, or Attending (ROPA) provider. ROPA providers must be enrolled with Florida Medicaid in accordance with Title 42, Code of Federal Regulations, Section 455.410(b).

Starting October 1, 2021, claims will not pay for any practitioner, group practice, facility, or pharmacy providing services to Florida Medicaid recipients based on a ROPA provider’s referral, order, prescription, or attending services, unless the ROPA provider identified by NPI on the FFS claim is actively enrolled with Florida Medicaid. This includes claims submitted to Florida Medicaid by institutional providers and paid at a calculated reimbursement rate.

Florida Medicaid features a quick and easy, automated ROPA provider enrollment application on the Florida Medicaid Web Portal Enrollment Application Wizard page.

Please visit the ROPA Provider Enrollment page of the Web Portal for updated information, including the Unenrolled ROPA Provider List, ROPA Providers Frequently Asked Questions and Quick Reference Guides on ROPA provider enrollment and claims billing.

Providers may call the Provider Services Contact Center at 1-800-289-7799, option 7, for billing assistance and option 4 for enrollment assistance.

QUESTIONS? FLMedicaidManagedCare@ahca.myflorida.com

COMPLAINTS OR ISSUES? ON LINE http://ahca.myflorida.com/Medicaid/complaints/ | CALL 1-877-254-1055

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Biden-Harris Administration to Expand Vaccination Requirements for Health Care Settings

Fri, 10 Sep 2021 16:42:08 GMT

MLN Connects® -- Special Edition - Thursday, September 9, 2021

New action will protect patients of the 50,000 providers and over 17 million health care workers in Medicare and Medicaid certified facilities

The Biden-Harris Administration will require COVID-19 vaccination of staff within all Medicare and Medicaid-certified facilities to protect both them and patients from the virus and its more contagious Delta variant. Facilities across the country should make efforts now to get health care staff vaccinated to make sure they are in compliance when the rule takes effect.

The Centers for Medicare & Medicaid Services (CMS), in collaboration with the Centers for Disease Control and Prevention (CDC), announced that emergency regulations requiring vaccinations for nursing home workers will be expanded to include hospitals, dialysis facilities, ambulatory surgical settings, and home health agencies, among others, as a condition for participating in the Medicare and Medicaid programs. The decision was based on the continued and growing spread of the virus in health care settings, especially in parts of the U.S. with higher incidence of COVID-19.

"There is no higher priority for us than patient health and safety. As the Delta variant strengthens, the Biden-Harris Administration is committed to doing everything we can to keep patients, and those who care for them, safe," said U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra. "There is no question that staff, across any health care setting, who remain unvaccinated pose both direct and indirect threats to patient safety and population health. Ensuring safety and access to all patients, regardless of their entry point into the health care system, is essential."

Nursing homes with an overall staff vaccination rate of 75% or lower experience higher rates of preventable COVID infection. In CMS’s review of available data, the agency is seeing lower staff vaccination rates among hospital and End Stage Renal Disease (ESRD) facilities. To combat this issue, CMS is using its authority to establish vaccine requirements for all providers and suppliers that participate in the Medicare and Medicaid programs. Vaccinations have proven to reduce the risk of severe illness and death from COVID-19 and are effective against the Delta variant. CMS will continue to work closely with all Medicare and Medicaid certified facilities to ensure these new requirements are met.

"We know that those working in health care want to do what is best for their patients in order to keep them safe," said CMS Administrator Chiquita Brooks-LaSure. "As the Delta variant continues to spread, we know the best defense against it lies with the COVID-19 vaccine. Data show that the higher the level of vaccination rates among providers and staff, the lower the infection rate is among patients who are dependent upon them for care. Now is the time to act. I’m urging everyone, but especially those fighting this virus on the front lines, to get vaccinated and protect themselves, their families, and their patients from COVID-19."

CMS is developing an Interim Final Rule with Comment Period that will be issued in October. CMS expects certified Medicare and Medicaid facilities to act in the best interest of patients and staff by complying with new COVID-19 vaccination requirements. Health care workers employed in these facilities who are not currently vaccinated are urged to begin the process immediately. Facilities are urged to use all available resources to support employee vaccinations, including employee education and clinics, as they work to meet new federal requirements.

Source: First Coast Service Options Inc.

CMS Proposes Changes to Reduce Health Care Disparities Among Patients with Chronic Kidney Disease

Tue, 6 Jul 2021 14:10:17 GMT

CMS Proposes Changes to Reduce Health Care Disparities Among Patients with Chronic Kidney Disease and End-Stage Renal Disease

Proposed changes mark Innovation Center’s first direct effort to close health equity gaps

CMS proposed actions that aim to close health equity gaps by providing Medicare patients battling End-Stage Renal Disease (ESRD) with greater access to care, through the ESRD Prospective Payment System (PPS) annual rulemaking. This proposed rule would update ESRD PPS payment rates, make changes to the ESRD Quality Incentive Program (QIP), and modify the ESRD Treatment Choices (ETC) Model. The proposed changes to the ETC Model policies would aim to encourage dialysis providers to decrease disparities in rates of home dialysis and kidney transplants among ESRD patients with lower socioeconomic status, making the model the agency’s first CMS Innovation Center model to directly address health equity.

According to CMS Office of Minority Health studies on racial, ethnic, and socioeconomic factors, disadvantaged Medicare patients suffer from ESRD at higher rates. They are also more likely to experience higher hospital readmissions and costs, as well as receive in-center hemodialysis because their kidneys are no longer able to perform their function. Studies also indicate non-white ESRD patients are less likely to receive pre-ESRD kidney care, become waitlisted for a transplant or receive a kidney transplant.

“Health equity is at the center of our work here at CMS,” said CMS Administrator Chiquita Brooks-LaSure. “Today’s proposed rule is grounded in measures to ensure people with Medicare who suffer from chronic kidney disease have easy access to quality care and convenient treatment options. When CMS encourages dialysis providers to offer more options for Medicare patients to receive dialysis treatments, it can be life changing and lead to better health outcomes, greater autonomy and better quality of life for patients with kidney disease.”

The proposed changes to the ETC Model build on the current model by proposing to test a new health care approach that rewards ESRD facilities and managing clinicians participating in the model for achieving significant improvement in the rates of home dialysis and kidney transplants for lower income beneficiaries. If finalized, these changes would take effect Jan. 1, 2022.

Consistent with President Biden’s Executive Order 13985 on Advancing Racial Equity and Support for Underserved Communities through the Federal Government, CMS is addressing health inequities and improving patient outcomes in the U.S. through improved data collection for better measurement and analysis of disparities across programs and policies. CMS is soliciting feedback in this proposed rule on opportunities to collect and leverage diverse sets of data. This includes race, ethnicity, Medicare/Medicaid dual eligible status, disability status, LGBTQ+ and socioeconomic status. It also includes new methodological approaches to advance equity through the ESRD Quality Incentive Program (ESRD QIP).

The rule includes proposals under the ESRD QIP to address the circumstances of the COVID-19 Public Health Emergency (PHE), such as not scoring or reducing payment to any facility in 2022 based on data from 2020. Regarding COVID-19 vaccination measures, the proposed rule requests stakeholder feedback on the feasibility of incorporating COVID-19 Healthcare Provider and Patient Vaccination measures in the ESRD QIP measure set. Currently, nearly 90% of all dialysis facilities are reporting vaccination data performance to the Center for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN). CMS is evaluating options for publicly reporting the data on official CMS datasets that compare the quality of care provided in Medicare-certified dialysis facilities nationwide.

CMS’ proposed rule includes several requests for information for the agency to consider as part of its goal to increase access to dialysis treatments at home. Currently, Medicare will only pay for dialysis at an ESRD facility for patients with Acute Kidney Injury (AKI). CMS is soliciting comments regarding potentially modifying the site of renal dialysis services for patients with AKI and payment for AKI in the home setting.

More Information:

CMS Announcement on MIPS Cost Category

Fri, 21 May 2021 13:01:17 GMT

Today, the Centers for Medicare & Medicaid Services (CMS) announced that the 2020 MIPS Cost Performance Category will be reweighted to 0% of the final score even if eligible physicians or groups submitted 2020 data in other MIPS categories in light of the impact of the COVID-19 pandemic. For over a year, the AMA has been recommending that CMS zero out this category during the pandemic for several reasons, including concerns that decreases in patient visits and increases in the costs of caring for patients with COVID-19 could unfairly penalize physicians. We applaud CMS for holding physicians harmless from unfair evaluations in the MIPS Cost Performance Category as a result of the COVID-19 pandemic.

The AMA also strongly supports CMS’ decision to release the 2018 and 2019 cost measure benchmark files, which we will review closely to identify the target spending for those years, how the benchmarks capture any variations in spending, and whether the benchmarks are leading to fair and valid comparisons among physicians. Again, the AMA has been recommending to CMS for a while that the agency should publish the data. In April, the AMA and 47 national medical specialty societies sent a letter urging CMS to immediately release the MIPS cost benchmarks to increase transparency in how the agency evaluates physician performance in the Cost Performance Category in MIPS and to allow physicians and other stakeholders to assess the measures for validity and opportunities to reduce spending. We anticipate this information will be informative for specialty societies that are engaged in the ongoing development of new episode-based cost measures and MIPS Value Pathways (MVPs).

CMS Starts Recouping Medicare Payments Made To Health Care Providers Last Year During The Pandemic

Tue, 6 Apr 2021 16:16:36 GMT

RevCycle Intelligence (4/5, LaPointe) reports, “CMS has started recouping Medicare payments it fronted to [health care] providers last year during the COVID-19 pandemic.” CMS “stated that it has begun recovering the payments through the COVID-19 Accelerated and Advance Payments (CAAP) on March 30, 2021, and will continue recoupment depending on the one year anniversary of when providers received their first payment.”

CMS Puts Patients Over Paperwork with New Rule that Addresses the Prior Authorization Process

Fri, 15 Jan 2021 16:52:55 GMT

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Final rule gives providers access to patient treatment histories, and streamlines prior authorization to improve patient experience and alleviate burden for health care providers

Today, the Centers for Medicare & Medicaid Services (CMS) finalized a signature accomplishment of the new Office of Burden Reduction & Health Informatics (OBRHI). This final rule builds on the efforts to drive interoperability, empower patients, and reduce costs and burden in the healthcare market by promoting secure electronic access to health data in new and innovative ways. These significant changes include allowing certain payers, providers and patients to have electronic access to pending and active prior authorization decisions, which should result in fewer repeated requests for prior authorizations, reducing costs and onerous administrative burden to our frontline providers. This final rule will result in providers having more time to focus on their patients and provide higher quality care.

“Today, we take a historic stride toward the future long promised by electronic health records but never yet realized: a more efficient, convenient, and affordable healthcare system,” said CMS Administrator Seema Verma. “Thanks to this rule, millions of patients will no longer have to wrangle with prior providers or locate ancient fax machines to take possession of their own data. Many providers, too, will be freed from the burden of piecing together patients’ health histories based on incomplete, half-forgotten snippets of information supplied by the patients themselves, as well as the most onerous elements of prior authorization. This change will reverberate around the healthcare system for years and decades to come.”

The “CMS Interoperability and Prior Authorization” rule is the next phase of CMS interoperability rulemaking, aimed at improving data exchange while simultaneously reducing provider and patient burden. This final rule requires the payers regulated under this rule (namely, Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs (FFS) and issuers of individual market Qualified Health Plans (QHPs) on the Federally-facilitated exchanges (FFEs)) to implement application programing interfaces (APIs) that will give providers better access to data about their patients, and streamline the process of prior authorization. APIs are the foundation of smartphone applications, and when integrated with a provider’s electronic health record (EHR), they can enable data access at the touch of a button. By exchanging relevant health information between patients, providers and payers, APIs support a better health care experience for patients. Patients have easier access to their own health information, their providers have a more complete picture of their care, and patients can take their information with them as they move from plan to plan, and from provider to provider throughout the healthcare system. This ensures more coordinated, quality care, and less repetitive and unnecessary care that is costly.

Today’s final rule requires Medicaid and CHIP (FFS) programs, Medicaid and CHIP managed care plans, and issuers of individual market QHPs on the FFEs to include, as part of the already established Patient Access API, claims and encounter data, including laboratory results, and information about the patient’s pending and active prior authorization decisions. These payers are also required to share this data directly with patients’ providers if they ask for it and with other payers as the patient moves from one payer to another. In this way, patients, providers, and payers have the data when and where they need it, to help ensure that patients receive the best possible care. While Medicare Advantage plans are not included in and therefore not subject to this final rule, CMS is considering whether to do so in future rulemaking.

Prior Authorization Burden Reduction

Payers use prior authorization as a way to manage health care costs and ensure payment accuracy. For certain services, providers request approval from payers before rendering care to ensure that the payer will determine that the care is medically necessary, a threshold requirement for care to be reimbursed under the patients’ health coverage. This administrative process can be burdensome, and the challenges of the prior authorization process have motivated industry efforts to develop tools to increase automation. This final rule aims to reduce the inefficiencies and burdens of the prior authorization process for providers, and give them back time to focus on what matters most, treating patients in a timely manner.

The final rule requires Medicaid and CHIP FFS programs, Medicaid and CHIP managed care plans, and issuers of individual market QHPs on the FFEs to build, implement, and maintain APIs using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard to support automation of the prior authorization process, specifically addressing the challenges raised by both providers and payers. The requirements of this rule specify that each of these payers will build an API-enabled documentation requirements look-up service, and make these public so providers may access documentation and prior authorization requirements from their EHR platforms. Once a provider knows what is required for each prior authorization, the next step is submitting it electronically.The final rule also requires Medicaid, CHIP, and QHP payers to implement and maintain prior authorization support APIs using the HL7 FHIR standard, which will advance a streamlined approach for communicating prior authorization requests and responses between those payers and provider EHR platforms or other practice management systems.

The final rule also requires Medicaid and CHIP (FFS) programs, and Medicaid and CHIP managed care plans to meet reduced decision timelines for prior authorizations. These payers will now have a maximum of 72 hours to make prior authorization decisions on urgent requests and seven calendar days for non-urgent requests, and all payers subject to the rule are required to provide a specific reason for any denial, which will allow providers some transparency into the process beginning January 1, 2024 or the rating period that starts on or after January 1, 2024.In addition, to promote accountability, the rule requires these payers, to make public, prior authorization metrics that demonstrate how they operationalize the prior authorization process. All of these requirements together will promote a more streamlined and efficient prior authorization process for providers and payers alike.

The rule will improve the patient experience as well. When a patient sees, for instance that a prior authorization is needed and has been submitted for a particular item or service, they will better understand the timeline for the process and be able to work with their provider to plan accordingly.

Today’s final rule aims to improve longstanding inefficiencies in the healthcare system —including the lack of data sharing and access. This final rule expands the current Administration’s goals of quality and lower costs in health care as payers and providers will now have access to more complete patient histories, allowing for more coordinated and seamless patient care.

The final rule is available to review today at: https://www.cms.gov/files/document/11521-provider-burden-promoting-patients-electronic-access-health-information-e-prior.pdf

Extension of the PHE & Implementation of Medicare Payment Changes in Consolidated Appropriations Act

Mon, 11 Jan 2021 14:24:38 GMT

HHS Secretary Azar has extended the COVID-19 Public Health Emergency (PHE) declaration effective Jan. 21, 2021 for an additional 90 days. This means that all of the telehealth and other waivers and flexibilities that have been implemented during the PHE will remain in effect until at least April 21, 2021.

In addition, as indicated in the summary and impact table distributed earlier this week, the Consolidated Appropriations Act that was signed into law on Dec. 27, 2020, included provisions that offset most of the 10.2% budget neutrality adjustment that had been slated to take effect for Medicare-covered services provided as of Jan. 1, 2021. CMS has now confirmed that it is implementing the following provisions of this legislation and that there will be no delay in claims processing for 2021 services; that is, claims will be paid on time at the correct 2021 rates that reflect this legislation.

Message from CMS:

On December 27, the Consolidated Appropriations Act, 2021 modified the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS):

Provided a 3.75% increase in MPFS payments for CY 2021
Suspended the 2% payment adjustment (sequestration) through March 31, 2021
Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023
Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024

CMS has recalculated the MPFS payment rates and conversion factor to reflect these changes. The revised MPFS conversion factor for CY 2021 is 34.8931. The revised payment rates are available in the Downloads section of the CY 2021 Physician Fee Schedule final rule (CMS-1734-F) webpage.

Source: AMA

CMS Proposes New Rules to Address Prior Authorization and Reduce Burden on Patients and Providers

Fri, 11 Dec 2020 19:10:12 GMT

Source: CMS

Today, under President Trump’s leadership, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would improve the electronic exchange of health care data among payers, providers, and patients, and streamline processes related to prior authorization to reduce burden on providers and patients. By both increasing data flow, and reducing burden, this proposed rule would give providers more time to focus on their patients, and provide better quality care.

The COVID-19 pandemic has shone a harsh light on many longstanding inefficiencies in the health care system—including the lack of data sharing and access. Today’s proposed rule aims to improve this for patients navigating care. The proposed rule would build on the Trump Administration’s Interoperability and Patient Access final rule published by the CMS in May.

“This proposed rule ushers in a new era of quality and lower costs in health care as payors and providers will now have access to complete patient histories, reducing unnecessary care and allowing for more coordinated and seamless patient care. Each element of this proposed rule would play a key role in reducing onerous administrative burden on our frontline providers while improving patient access to health information,” said CMS Administrator Seema Verma. “Prior authorization is a necessary and important tools for payors to ensure program integrity, but there is a better way to make the process work more efficiently to ensure that care is not delayed and we are not increasing adminsitrative costs for the whole system.” Prior authorization is not only a leading source of burden, it is also a primary source of provider burnout, and takes time away from treating patients. If just a quarter of providers took advantage of the new electronic solutions that this proposal would make available, the proposed rule would save between 1 and 5 billion dollars over the next ten years. With the pandemic placing even greater strain on our health care system, the policies in this rule are more vital than ever.”

The rule would require payers in Medicaid, CHIP and QHP programs to build application programming interfaces (APIs) to support data exchange and prior authorization. APIs allow two systems, or a payer’s system and a third-party app, to communicate and share data electronically Payers would be required to implement and maintain these APIs using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard. The FHIR standard is an innovative technology solution that helps bridge the gaps between systems so both systems can understand and use the data they exchange.

On behalf of HHS, the Office of the National Coordinator for Health IT (ONC) is also proposing to adopt certain standards through an HHS rider on the CMS proposed rule.

Improving Prior Authorization

Prior authorization is an administrative process used in healthcare for providers to request approval from payers to provide a medical service, prescription, or supply. This process takes place before a service is rendered. The rule proposes significant changes to improve the patient experience and alleviate some of the administrative burden prior authorization causes health care providers. Medicaid, CHIP and QHP payers would be required to build and implement FHIR-enabled APIs that could allow providers to know in advance what documentation would be needed for each different health insurance payer, streamline the documentation process, and enable providers to send prior authorization requests and receive responses electronically, directly from the provider’s EHR or other practice management system. While Medicare Advantage plans are not included in today’s proposals, CMS is considering whether to do so in future rulemaking.

The proposed rule would also reduce the amount of time providers wait to receive prior authorization decisions from payers—the rule proposes a maximum of 72 hours for payers, with the exception of QHP issuers on the FFEs, to issue decisions on urgent requests and seven calendar days for non-urgent requests. Payers would also be required to provide a specific reason for any denial, which will allow providers some transparency into the process. To promote accountability for plans, the rule also requires them to make public certain metrics that demonstrate how many procedures they are authorizing.

These policies, taken together, could lead to fewer prior authorization denials and appeals, while improving communication and understanding between payers, providers, and patients. They are the result of numerous listening sessions with plans and providers aimed at crafting a new process that balances the need for greater efficiency and consistency in prior authorization and its important role in preventing fraud, abuse, and unnecessary expenditures.

Increasing Patient Access to Health Information

Building on that foundational policy, this rule would require impacted payers to implement and maintain a FHIR-based API to exchange patient data as patients move from one payer to another. In this way, patients who would otherwise not have access to their historic health information would be able to bring their information with them when they move from one payer to another, and would not lose that information simply because they changed payers.

These proposed changes would also allow payers, providers and patients to have access to more information including pending and active prior authorization decisions, potentially allowing for fewer repeat prior authorizations, reducing burden and cost, and ensuring patients have better continuity of care. To read more on the importance of these proposed changes, please visit CMS Administrator Seema Verma’s blog post here: https://www.cms.gov/blog/reducing-provider-and-patient-burden-and-promoting-patients-electronic-access-health-information

The proposed rule is available to review today at: https://www.cms.gov/files/document/121020-reducing-provider-and-patient-burden-cms-9123-p.pdf The comment period will close on January 4, 2021.

For a copy of the Fact Sheet, visit: https://www.cms.gov/newsroom/fact-sheets/reducing-provider-and-patient-burden-improving-prior-authorization-processes-and-promoting-patients

For more information on the CMS proposed rule, please visit: https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index

CMS Proposes New Rules To Address Prior Authorization

Fri, 11 Dec 2020 14:08:38 GMT

CMS Proposes New Rules to Address Prior Authorization and Reduce Burden on Patients and Providers

On December 10, under President Trump’s leadership, CMS issued a proposed rule that would improve the electronic exchange of health care data among payers, providers, and patients and streamline processes related to prior authorization to reduce burden on providers and patients. By both increasing data flow and reducing burden, this proposed rule would give providers more time to focus on their patients and provide better quality care.

For More Information:

Proposed Rule: Comment period closes January 4
Full press release
Fact sheet
Blog
CMS Interoperability and Patient Access Final Rule webpage
Register for December 16 listening session

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Permanent Expansion of Medicare Telehealth Services

Tue, 8 Dec 2020 18:14:31 GMT

TRUMP ADMINISTRATION FINALIZES PERMANENT EXPANSION OF MEDICARE TELEHEALTH SERVICES AND IMPROVED PAYMENT FOR TIME DOCTORS SPEND WITH PATIENTS

On December 1, CMS released the annual Physician Fee Schedule (PFS) final rule, prioritizing CMS’ investment in primary care and chronic disease management by increasing payments to physicians and other practitioners for the additional time they spend with patients, especially those with chronic conditions. The rule allows non-physician practitioners to provide the care they were trained and licensed to give, cutting red tape so health care professionals can practice at the top of their license and spend more time with patients instead of on unnecessary paperwork. This final rule takes steps to further implement President Trump’s Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors including prioritizing the expansion of proven alternatives like telehealth.

“During the COVID-19 pandemic, actions by the Trump Administration have unleashed an explosion in telehealth innovation, and we’re now moving to make many of these changes permanent,” said HHS Secretary Alex Azar. “Medicare beneficiaries will now be able to receive dozens of new services via telehealth, and we’ll keep exploring ways to deliver Americans access to health care in the setting that they and their doctor decide makes sense for them.”

“Telehealth has long been a priority for the Trump Administration, which is why we started paying for short virtual visits in rural areas long before the pandemic struck,” said CMS Administrator Seema Verma. “But the pandemic accentuated just how transformative it could be, and several months in, it’s clear that the health care system has adapted seamlessly to a historic telehealth expansion that inaugurates a new era in health care delivery.”

Finalizing Telehealth Expansion and Improving Rural Health

Before the COVID-19 Public Health Emergency (PHE), only 15,000 Fee-for-Service beneficiaries each week received a Medicare telemedicine service. Since the beginning of the PHE, CMS has added 144 telehealth services, such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services, that are covered by Medicare through the end of the PHE. These services were added to allow for safe access to important health care services during the PHE. As a result, preliminary data show that between mid-March and mid-October 2020, over 24.5 million out of 63 million beneficiaries and enrollees have received a Medicare telemedicine service during the PHE.

This final rule delivers on the President’s recent Executive Order on Improving Rural Health and Telehealth Access by adding more than 60 services to the Medicare telehealth list that will continue to be covered beyond the end of the PHE, and we will continue to gather more data and evaluate whether more services should be added in the future. These additions allow beneficiaries in rural areas who are in a medical facility (like a nursing home) to continue to have access to telehealth services such as certain types of emergency department visits, therapy services, and critical care services. Medicare does not have the statutory authority to pay for telehealth to beneficiaries outside of rural areas or, with certain exceptions, allow beneficiaries to receive telehealth in their home. However, this is an important step, and as a result, Medicare beneficiaries in rural areas will have more convenient access to health care.

Additionally, CMS is announcing a commissioned study of its telehealth flexibilities provided during the COVID-19 PHE. The study will explore new opportunities for services where telehealth and virtual care supervision, and remote monitoring can be used to more efficiently bring care to patients and to enhance program integrity, whether they are being treated in the hospital or at home.

Payment for Office/Outpatient Evaluation and Management (E/M) and Comparable Visits

Last year, CMS finalized a historic increase in payment rates for office/outpatient face-to-face E/M visits that goes into effect in 2021. The Medicare population is increasing, with over 10,000 beneficiaries joining the program every day. Along with this growth in enrollment is increasing complexity of beneficiary health care needs, with more than two-thirds of Medicare beneficiaries having two or more chronic conditions. Increasing the payment rate of E/M office visits recognizes this demand and ensures clinicians are paid appropriately for the time they spend on coordinating care for patients, especially those with chronic conditions. These payment increases, informed by recommendations from the American Medical Association (AMA), support clinicians who provide crucial care for patients with dementia or manage transitions between the hospital, nursing facilities, and home.

Under this final rule, CMS continues to prioritize this investment in primary care and chronic disease management by similarly increasing the value of many services that are similar to E/M office visits, such as maternity care bundles, emergency department visits, end-stage renal disease capitated payment bundles, and physical and occupational therapy evaluation services. These adjustments ensure CMS is appropriately recognizing the kind of care where clinicians need to spend more face-to-face time with patients.

“This finalized policy marks the most significant updates to E/M codes in 30 years, reducing burden on doctors imposed by the coding system and rewarding time spent evaluating and managing their patients’ care,” Administrator Verma added. “In the past, the system has rewarded interventions and procedures over time spent with patients – time taken preventing disease and managing chronic illnesses.”

In addition to the increase in payment for E/M office visits, simplified coding and documentation changes for Medicare billing for these visits will go into effect beginning January 1, 2021. The changes modernize documentation and coding guidelines developed in the 1990s, and come after extensive stakeholder collaboration with the AMA and others. These changes will significantly reduce the burden of documentation for all clinicians, giving them greater discretion to choose the visit level based on either guidelines for medical decision-making (the process by which a clinician formulates a course of treatment based on a patient’s information, i.e., through performing a physical exam, reviewing history, conducting tests, etc.) or time dedicated with patients. These changes are expected to save clinicians 2.3 million hours per year in administrative burden so that clinicians can spend more time with their patients.

Professional Scope of Practice and Supervision

As part of the Patients Over Paperwork Initiative, the Trump Administration is cutting red tape so that health care professionals can practice at the top of their license and spend more time with patients instead of on unnecessary paperwork. The PFS final rule makes permanent several workforce flexibilities provided during the COVID-19 PHE that allow non-physician practitioners to provide the care they were trained and licensed to give, without imposing additional restrictions by the Medicare program.

Specifically, CMS is finalizing the following changes:

Certain non-physician practitioners, such as nurse practitioners and physician assistants, can supervise the performance of diagnostic tests within their scope of practice and state law, as they maintain required statutory relationships with supervising or collaborating physicians.
Physical and occupational therapists will be able to delegate “maintenance therapy” – the ongoing care after a therapy program is established – to a therapy assistant.
Physical and occupational therapists, speech-language pathologists, and other clinicians who directly bill Medicare can review and verify, rather than re-document, information already entered by other members of the clinical team into a patient’s medical record. As a result, practitioners have the flexibility to delegate certain types of care, reduce duplicative documentation, and supervise certain services they could not before, increasing access to care for Medicare beneficiaries.

For More Information:

Final Rule
Physician Fee Schedule Final Rule fact sheet
Quality Payment Program Final Rule fact sheet and FAQs
Medicare Diabetes Prevention Program fact sheet

SOURCE:
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TRADEMARKS OF THEU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS).
Centers for Medicare & Medicaid Services and The Medicare Learning Network

CMS finalizes Stark Law overhaul: 6 things to know

Tue, 24 Nov 2020 19:57:36 GMT

Alia Paavola - Friday, November 20th, 2020 Becker's Hospital Review

CMS issued a final rule Nov. 20 that modifies the Stark Law, which prohibits physician self-referrals.

Six things to know:

1. The agency proposed the changes to the Stark Law in October 2019, arguing that the law hasn't evolved with the transition to value-based care.

2. The final rule provides exceptions to the law for certain value-based compensation arrangements between or among physicians, other providers and suppliers.

3. The rule has an exception for some arrangements in which a physician receives remuneration for items or services provided by the physician.

4. It also has a new exception for donations of cybersecurity technology and services and amends the existing exception for EHR items and services.

5. The modifications take effect Jan. 19.

6. The changes are the most significant alterations to the law since its 1989 inception, according to CMS.

"The final rule unleashes innovation by permitting physicians and other healthcare providers to design and enter into value-based arrangements without fear that legitimate activities to coordinate and improve the quality of care for patients and lower costs would violate the Stark Law," CMS said in its news release.

CMS Finalizes Policy that will Increase the Number of Available Lifesavings Organs by Holding Organ

Tue, 24 Nov 2020 14:57:11 GMT

CMS Finalizes Policy that will Increase the Number of Available Lifesavings Organs by Holding Organ Procurement Organizations Accountable through Transparency and Competition

Today, the Centers for Medicare & Medicaid Services (CMS) is finalizing a rule that is designed to increase the supply of lifesaving organs available for transplant in the United States by requiring that the organizations responsible for organ procurement be transparent in their performance, highlighting the best and worst performers, and requiring them to compete on their ability to successfully facilitate transplants.

The rule enacts sweeping reform of the Medicare Conditions for Coverage (CfCs) for Organ Procurement Organizations (OPOs). OPOs, which are entities that seek organs for the 113,000 Americans on waitlists, must meet minimum quality measure thresholds in the CfCs to receive Medicare and Medicaid payment. The current measures are based on self-reported data and disincentivize OPOs from aggressively seeking any and all available organs. The rule creates new measures designed to hold OPOs accountable for seeking – and ensuring transplant of – as many organs as possible, and the calculation of the measures is based on objective data. The rule is designed to increase the number of organs available for transplant, helping tackle one of the longstanding problems in the organ transplant system, namely that the need for organs greatly exceeds the supply. Indeed, as the capstone of President Trump’s July 2019 Executive Order on Advancing American Kidney Health, the rule is the last of a long list of Trump Administration actions designed to increase the supply of donated organs for Americans on waitlists for lifesaving transplants.

“Thousands of Americans are languishing on organ waitlists, and twenty Americans every day die waiting for an organ. This is unacceptable and the Trump Administration is acting. Today’s final rule is an opportunity to improve the quality of life for millions of Americans,” said CMS Administrator Seema Verma. “Organ transplants offer hope for a fuller life untethered from dialysis machines and waiting lists. We’re helping to increase the supply of donated organs available for transplant by making sure OPOs are performing at optimal levels.”

Under current rules, OPOs must meet minimum thresholds of two of three outcome measures: the donation rate of eligible donors, the observed – or actual – donation rate, and donor yield (meaning the number of procured organs donated per donor). The existing measures are calculated using data self-reported from OPOs. CMS had heard from stakeholders that these measures and the self-reported data disincentivized OPOs from seeking as many organs as possible, like less-than-perfect organs that would nevertheless be lifesaving for some recipients. CMS is replacing the existing three quality measures with two new measures, and calculating them based on objective data. The first new measure is a donation rate measure; it measures the number of organs an OPO has procured from eligible donors in its donation service area. It is designed to ensure OPOs pursue all potential donors, even those only able to donate one organ. The second measure is an organ transplantation rate measure. No longer will OPOs be required to simply procure an organ; it must actually be transplanted. This creates an incentive for OPOs to transplant and use all viable organs. The measures are calculated using objective data from the Health Resources and Services Administration (HRSA) and the Centers for Disease Control (CDC). Under the new rules, underperforming OPOs will compete for their organizational contracts – which are necessary for them to function as OPOs – and the worst performers will be unable to renew their contracts.

The number of Americans on waiting lists far exceeds the number of available donor organs. The long wait for organs can be devastating for patients and families, especially those suffering with kidney disease. Many of these patients progress to late-stage kidney failure, face high mortality rates, only have treatment options that are expensive and do not produce an acceptable quality of life, and, perhaps most disappointing, are unable to receive transplants because there are not enough kidneys donated to meet the current demand for transplants. This final rule directly benefits each person currently waiting for a transplant because it will increase the supply of available organs by encouraging OPOs to procure as many organs as possible, a goal of the President’s Executive Order.

A key part of the organ donation system, OPOs are non-profit organizations responsible for evaluating and procuring organs for transplant from deceased donors. These organizations also provide support to donor families, clinical management of organ donors, and professional and public education about organ donation. Currently, there are 58 OPOs in the United States, each assigned to its own DSA. Several government agencies, including CMS, regulate different aspects of the U.S. organ transplant system. Federal law tasks CMS with conducting surveys of OPOs and recertifying them (no less frequently than every four years) based on whether they meet the OPO CfCs, which include outcome and process measures.

While OPOs are a critical part of the organ donation system in the United States, some stakeholders have argued that many are underperformers and have faced few consequences for their poor performance. Current organ recovery and transplantation measure regulations are outdated and allow OPOs to subjectively report organ recovery rates. For example, currently OPOs can self-report eligible donor pool numbers. This means that they can exclude data for donors that have a lower likelihood of providing a viable organ. This self-reporting means they may be able to manipulate their measure performance in a way that makes it appear better than reality.

The specific areas in which CMS is finalizing changes to OPOs include the following:

The first measure change is to the donation rate measure. The changes encourage OPOs to pursue all potential donors, even those who are only able to donate one organ.

The second measure change is to the organ transplantation rate measure. OPOs will no longer receive credit for simply procuring an organ – it must be actually transplanted to count. This creates an incentive for OPOs to procure and match all viable organs with recipients. CMS is also no longer accepting self-reported data from OPOs and will instead calculate outcome measures using death certificate data, a more reliable verifiable data source to calculate OPO’s outcome measures.

CMS is making outcome measure performance public to increase transparency. This will highlight OPOs that fall outside of the top 25% in donation and transplantation rates and helps OPOs identify areas for improvement, giving them an opportunity to take timely action to save more lives. The increased accountability – to the public and to CMS alike – promises to incentivize OPOs to procure more organs for transplantation.
Under the final rule, OPOs are encouraged to match the lowest donation and transplantation rates of the top 25% of OPOs, a ranking that will be publicly available annually. OPOs with rates that are below the top 25% will be required to take action to improve their rates through a quality assurance and performance improvement (QAPI) program. Reviewing OPO performance every 12 months will allow CMS to more quickly identify OPOs that need improvement.

Today’s final rule is only one of many actions the Trump Administration is taking through CMS related to kidney care and organ donation. The agency is also working to improve outcomes for transplant candidates and patients, as well as thousands of Medicare beneficiaries who undergo costly and burdensome in-center dialysis treatments. Many of CMS’s efforts were announced in President Trump’s 2019 Executive Order on Advancing American Kidney Health, including a CMS-led stakeholder learning system, as part of the End-stage Renal Disease (ESRD) Treatment Choices Model. The learning system, which was finalized on September 29, 2020, will work with participants in the ETC Model and other key stakeholders, such as transplant centers and OPOs, and use learning and quality improvement techniques to help increase the availability of deceased donor kidneys for transplant.

For a fact sheet on the final rule (CMS-3380-F), please visit: https://www.cms.gov/newsroom/fact-sheets/organ-procurement-organization-opo-conditions-coverage-final-rule-revisions-outcome-measures-opos

To view the final rule (CMS-3380-F), please visit: https://www.cms.gov/files/document/112020-opo-final-rule-cms-3380-f.pdf

### Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter CMS Administrator @SeemaCMS and @CMSgov.

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