Jan. 12, 2024: National Advocacy Update

On Dec. 15, 2023, the federal independent dispute resolution (IDR) portal reopened to all claim types, including batched claim disputes and disputes involving air ambulances. Due to the disruption caused by the IDR portal being down for several months, IDR initiation deadlines have been extended for several types of disputes. More information can be found on the CMS website.

Several flexibilities will also be in place through Jan. 16, 2024, for all dispute types, including:

• Additional time to respond to certified IDR entity requests for additional information (must be requested)
• An additional 10 business days to submit an offer (must be requested)
• 10 additional business days to select a certified IDR entity (applied automatically)

For disputes filed between Aug. 3, 2023, and Jan. 21, 2024, the administrative fee will be $50 per party per dispute. On Dec. 18, 2023, CMS issued a final rule increasing the administrative fee to $115 per party per dispute and the certified IDR entity fee to a range of $200-$840 for single determinations and $268-$1,173 or more for batched determinations (depending on the number of line items). These updated fees will apply to disputes filed on or after Jan. 22, 2024. The rule also dictates that any future rate changes will be announced in notice and comment rulemaking, as opposed to guidance. The administration had previously sought to increase administrative fees to $350 through guidance, but this was struck down by a lawsuit brought by the Texas Medical Association (TMA IV).

On Jan. 2, 2024, the AMA submitted comments (PDF) in response to a proposed rule (PDF) with potential changes to the IDR process. The AMA was overall supportive as several of the changes reflect longstanding AMA recommendations, including required use of Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) with initial payments or notices of denial, mandatory use of the IDR portal to confirm both parties are in fact participating in the open negotiations process, required responses to initiating notices, lower administrative fees in certain circumstances and expanded flexibilities for batching claims, though the AMA did push back on the proposed limit of 25 line items per batched claim. Overall, the AMA believes the proposed changes will help improve the efficiency and speed of the IDR process. The initial comment period closed Jan. 2 but the Centers for Medicare & Medicaid Services (CMS) plans to reopen comments at a later date, yet to be announced. All comments will be given the same level of consideration.

The National Association Medical Staff Services (NAMSS) this week published a 2024 revision of its Ideal Credentialing Standards (ICS) that includes language consistent with recommendations from the AMA and the Dr. Lorna Breen Heroes Foundation (DLBHF) for inquiring about practitioner health status. The AMA and DLBHF worked closely with NAMSS on the revisions, which remove mandated disclosures about past diagnosis or treatment of mental illness and substance use disorders. The NAMSS membership includes more than 6,000 medical staff and credentialing services professionals (MSPs) from medical group practices, hospitals, managed care organizations, and credentialing verification organizations. 

The current recommended questions regarding health and wellness align directly with AMA policy and ask an applicant:

• Are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgment or that would otherwise adversely affect your ability to practice medicine in a competent, ethical, and professional manner? (Yes/No) 

“The AMA deeply appreciates and commends NAMSS for its national leadership and commitment to supporting physicians’ health and wellness through removing stigmatizing questions about past treatment of mental health and substance use disorders from the NAMSS credentialing standards,” said AMA President Jesse M. Ehrenfeld, MD, MPH. “The next step is for all hospitals and health systems to review their own credentialing questions and policies to ensure they are consistent with NAMSS national best practices. The AMA and Dr. Lorna Breen Heroes' Foundation stand ready to work with every hospital and health system in the nation to update their credentialing applications to ensure they support physicians' and all health care professionals' health and wellbeing."

The DLBHF and Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health (NIOSH) also supported the changes.

“Despite burnout and stress, healthcare workers are not seeking mental health care for fear of losing their jobs due to broad and invasive credentialing application questions,” said Corey Feist, JD, MBA, co-founder and CEO of the Dr. Lorna Breen Heroes’ Foundation. “We applaud NAMSS for taking a critical step to remove this barrier and protect the wellbeing of our healthcare workforce.” 

“We are excited to see NAMSS take this important step to address a substantial barrier to the wellbeing of credentialed healthcare workers through the revised ICS,” said Dr. John Howard, MD, Director of NIOSH. “Making systems-wide improvements is the best way to promote professional wellbeing, and steps like these lay the foundation for a thriving healthcare workforce.”

The AMA continues to work with dozens of hospitals and health systems to make similar changes. For more information about the AMA’s support for physician health and wellness, please visit the AMA website.

The AMA produced a comment letter (PDF) to the Office of the National Coordinator for Health IT (ONC) in response to the Proposed Regulation on Disincentives for Providers that have Committed Information Blocking. The regulation focuses on physicians and other health care providers determined by the Department of Health and Human Services (HHS) Office of Inspector General (OIG) to have committed information blocking that are also Medicare-enrolled providers or suppliers.

The AMA’s letter asked ONC to prioritize physician education and opportunities for corrective action over the imposition of harsh financial disincentives. Before imposing a disincentive, the AMA asked ONC, OIG and CMS to first provide educational resources and work with the physician or practice to establish a formal corrective action plan, which would then be closely monitored. The letter noted that starting with notice and corrective action is consistent with enforcement approaches undertaken in various other HHS efforts, especially when the underlying regulatory scheme is novel and complex.

The AMA’s comments also emphasized that the proposed disincentive construct will unfairly and arbitrarily penalize physicians, result in punishments that are not proportional to the underlying alleged misconduct, lack a meaningful mechanism for physicians to address allegations or appeal adverse determinations, and counterproductively, discourage participation in Medicare quality and value-based care programs and compound existing Medicare payment shortfalls.

Overall, the AMA voiced strong opposition to the persistent and egregious practice of information blocking, and discussed how it contravened the spirit of open and collaborative health care as well as undermined patient trust and safety. The letter also highlighted how the organization had been working to achieve the promise of EHRs and other health IT by promoting interoperability and ensuring that safe and usable technology is incorporated into all physician practice workflows.

In response to proposed regulations for Medicare Advantage (MA) plans in 2025, the AMA submitted a comment letter (PDF) supporting many of the CMS proposals as well as suggesting improvements. In response to a previous request for information, the AMA urged that MA plans be required to improve the adequacy of their networks for treating patients with opioid and substance use disorders. The AMA letter supports the current proposal to do just that through the establishment of a new Outpatient Behavioral Health requirement for MA networks. The AMA also cautioned, however, that expanded networks will have limited effect unless MA plans are also prohibited from imposing prior authorization, step therapy, fail first or quantity limits on medications for opioid use disorder.

The letter also discussed the AMA concerns with the current inefficiencies in electronic prescribing, especially lack of access to real-time patient cost-sharing information and labor-intensive prior authorization processes. The AMA appreciates CMS’ proposed improvements and is urging CMS to finalize its proposal to adopt updated standards for e-prescribing and real-time prescription benefit information.

Health equity is another focal issue in the AMA comment letter, which notes that MA plan use of prior authorization creates geographic and racial inequities throughout the health care system, with prior authorization denials by MA plans having a bigger impact on historically minoritized Medicare patient populations. The AMA is recommending that CMS require plans’ utilization management committees to include at least two independent physicians with expertise in health equity. The AMA also applauds CMS’ proposal that the utilization management committee must conduct an annual health equity analysis of the use of prior authorization at the plan level.

The letter also responds to CMS proposals regarding biosimilars, the prescription drug plan quality rating system, special supplemental benefits for the chronically ill, and it recommends that CMS develop a coordinated payment policy for the costs associated with MA plan enrollee participation in clinical trials.

On Jan. 11, as part of its “All Hands on Deck” approach to the Medicaid and CHIP unwinding, HHS launched a new centralized hub to house resources with the specific aim of avoiding gaps in coverage. The page sorts resources by several categories, including resources targeted towards specific groups of individuals, such as those living with disabilities. The resources are targeted at many different audiences, including template resources designed to be customized by individual states. HHS intends to update the page regularly as new resources are developed.

Last month, HHS also released a data snapshot (PDF) on Medicaid/CHIP enrollment focused on children and youth and an informational bulletin (PDF) extending several flexibilities designed to help children retain coverage through the end of 2024. In an accompanying press release, HHS Secretary Xavier Becerra also noted he had sent letters to the governors of nine states with the highest child disenrollment rates by number and percentage, urging them to adopt additional federal strategies and flexibilities to help prevent children and their families from losing coverage.

The AMA has been in regular communication with HHS to minimize disruptions to coverage related to the Medicaid and CHIP unwinding and to help educate physicians on available resources.

On Jan. 8, the AMA submitted a letter (PDF) to the U.S. Department of Health and Human Services (HHS) on the Patient Protection and Affordable Care Act Notice of Benefits and Payment Parameters (NBPP) for 2025. The letter was largely supportive of proposed changes, noting the importance of improving access to care, strengthening network adequacy and consumer protections, and streamlining enrollment and plan selection.

In the letter, the AMA underscored its strong position on network adequacy and indicated support for proposed provisions that would expand current federal requirements to issuers operating on state-based exchanges (SBEs) and state-based exchanges on the federal platform (SBE-FP), including time and distance standards and quantitative network adequacy reviews. The letter goes on to support proposals that would align special enrollment periods to reduce gaps in coverage, as well as proposals that would streamline and strengthen consumer protections for state essential health benefits benchmark plans. The AMA also applauded a proposal to establish new flexibilities for states to allow for customized plans for vulnerable patient populations, including those with high-cost, chronic conditions. HHS is expected to finalize the rule in Spring 2024.

The AMA National Advocacy Conference is only a month away—Feb. 12-14 at the Grand Hyatt in Washington, D.C. Register now and don’t forget to make your hotel reservation. The room block closes on Jan. 22.

Newly announced speakers include:

• Larry Bucshon, MD, United States Representative (R-IN)
• Richard Neal, United States Representative (D-MA)
• Mandy K. Cohen, MD, MPH, director, Centers for Disease Control and Prevention
• Lina Khan, chair, Federal Trade Commission

Additional featured speakers will include:

• Donna Brazile, renowned political strategist and commentator, former interim chair of the Democratic National Committee 
• Ana Navarro, GOP strategist, political contributor to CNN and Telemundo, and co-host of ABC’s The View 
• Geoff Bennett, PBS NewsHour co-anchor  
• Brian Miller, MD, MBA, MPH, practicing hospitalist at the Johns Hopkins Hospital, assistant professor of medicine at the Johns Hopkins University School of Medicine, and nonresident fellow at the American Enterprise Institute 

For more information and to help plan your travel, view the preliminary agenda (PDF).

Please contact [email protected] with any questions.

• Jan. 12, 2024: Medicare Payment Reform Advocacy Update