Jan. 13, 2023: National Advocacy Update

The AMA National Advocacy Conference is only a month away—Feb. 13-15 at the Grand Hyatt in Washington, D.C. Register now to make your voice heard on the crucial issues impacting medicine, including the need for systemic Medicare payment reform that ends unsustainable payment rates and reduction of administrative burdens like prior authorization that delay care and drive physician burnout.

For more information about why to attend, view this short video from AMA President Jack Resneck Jr., MD, on the top reasons why he will be attending this year’s Conference. The AMA National Advocacy Conference gives attendees the perfect opportunity to fight for a more sustainable health care system on Capitol Hill, hear about the latest issues from members of Congress and the Administration, and learn from other physician leaders.   

Featured speakers will include: 

• Michael Beschloss, presidential historian and bestselling author 
• April Ryan, White House reporter and political analyst 
• Bill Whitaker, CBS News correspondent on 60 Minutes 

Find more details in the agenda.  

Register now. 

In 2022, the AMA launched and made significant progress on our Recovery Plan for America’s Physicians—focused on fixing prior authorization, reforming Medicare payment, fighting scope creep, supporting telehealth and reducing physician burnout—but we’re not done yet. By building consensus, presenting evidence and mobilizing organized medicine, the AMA elevates physician voices to improve our nation’s health.  

Get the latest on the AMA’s federal and state advocacy agenda for 2023 in a Jan. 17 webinar at 11 a.m., Central. Hosted by Sandra Adamson Fryhofer, MD, chair of the AMA Board of Trustees, speakers will include:  

• Todd Askew, senior vice president, advocacy, AMA 
• Michaela Sternstein, vice president, Advocacy Resource Center, AMA 
• Jason Marino, director, Congressional affairs, AMA 

Additionally, leading up to the AMA National Advocacy Conference, save the date for another webinar hosted by Dr. Fryhofer on Feb. 7 at 11 a.m., Central, about the AMA’s advocacy on Capitol Hill and how you can get involved. Hear from: 

• Jack Resneck Jr., MD, president, AMA, about his experience being a physician leader pushing for change 
• Rob Jordan, director, political and legislative grassroots, AMA, about joining the AMA Physicians Grassroots Network and grassroots best practices 
• Jason Marino, director, Congressional affairs, AMA, about the power of physician voices at the AMA National Advocacy Conference 

Attendees will also get a sneak peek of some of the issues that will be covered at the AMA National Advocacy Conference. Registration link coming soon. 

On Dec. 23, 2022, the Centers for Medicare & Medicaid Services (CMS) released updated guidance (PDF) that dramatically increased the Independent Dispute Resolution (IDR) Process administrative fee from $50 to $350 for 2023, reversing an earlier decision to maintain the same fee. CMS states that the fee increase is needed to cover the costs associated with reducing the backlog of IDR claims that has continued to grow since announcing in Oct. that the fee would not increase. It is important to note that the administrative fee is paid by both parties and is nonrefundable, making this increase a significant barrier to the IDR process for many physician practices. The department also increased the maximum IDR Entity fees from $500 to $700 for individual claims (a 40% increase) and from $670 to as much as $1,219 for batched claims, an 82% increase.  

The agency also released a separate preliminary report (PDF) on the IDR Process based on data from mid-April-Sept. 2022. Over that time, more than 90,000 claims were received, more than originally anticipated. Of those, approximately one-quarter had been “resolved,” though only 15% of resolved claims resulted in a payment determination. Others were withdrawn/settled by the parties, had technical errors or were closed due to unpaid fees. Notably, more than two-thirds of claims were deemed ineligible, largely due to federal versus state authority issues, missing information or incorrect batching. The agency says it intends to follow up with a full report at a later date in an effort to allow certified IDR entities to focus on determinations, and the departments to focus on continuing to automate the IDR portal to improve dispute processing speeds in hopes of alleviating the current claims backlog. 

Under new guidance (PDF) to state health officials sent Jan. 5, 2023, for the first time ever, state Medicaid and CHIP programs will be able to pay specialists for consulting with a beneficiary’s primary health care provider. The goal of this new policy is to improve timely access to specialty providers and improve quality of care and health outcomes for both physical and behavioral health, as well as address health inequities. This letter clarifies that Medicaid and CHIP coverage and payment of interprofessional consultation is permissible, even when the beneficiary is not present, as long as the consultation is for the direct benefit of the beneficiary. This means the services must be directly relevant to the individual patient’s diagnosis and treatment, and the consulting practitioner must have specialized expertise in the particular health concerns of the patient.  

The new policy also supersedes previous policy by allowing the consulting fee to be paid as a distinct service, rather than counting toward a higher payment to the treating physician (only). If states choose to pay for these services, they must submit a state plan amendment to add a payment methodology for the qualifying interprofessional consultation service. States have flexibility in designing payment methodologies, though they are encouraged to review and consider the billing codes and payment rates Medicare has established for interprofessional consultations, for which Medicare established values for six CPT codes in 2019. Telehealth flexibilities will also apply to these consultation services. 

On Jan. 4, CMS released new guidance (PDF) to state Medicaid directors outlining a new set of streamlined requirements for Section 1115 social determinants of health waivers to be approved. The waivers are intended to improve beneficiary health and experience, reduce costs and reduce health disparities by providing services that address health-related social needs (HRSN) of Medicaid beneficiaries such as housing instability, nutrition insecurity and inpatient mental health or substance use disorder treatment services. The new guidance specifies that these supplemental services must advance the goals of the Medicaid program, be medically appropriate, cost-effective, optional for enrollees and have appropriate oversight and evaluation. CMS reserves the right to rescind its approval or require corrective action of any benefits should the agency determine they no longer meet these requirements.  

The cost of supplemental services is capped at 5% of total plan expenses. Plans with supplemental services accounting for greater than 1.5% of total plan expenses are subject to additional requirements, including a retrospective evaluation. The new guidance is effective for new ILOS agreements starting Jan. 4, 2023. However, states with existing ILOS agreements will have until the contract rating period beginning on or after Jan. 1, 2024, to comply.  

Under previous guidance (PDF), if a state’s proposed annual HRSN expenditure authority equals at least $50M or 0.5% of the state’s total annual Medicaid spend (whichever is less), they must meet the following requirements: the state’s Medicaid-to-Medicare rate ratios must be at least 80% for primary care, behavioral health and OB/GYN services. States that cannot fulfill this requirement with their existing rates must commit to increasing rates for their lowest-performing category by 2 percentage points. 

CMS issued new guidance (PDF) on Jan. 5, 2023, clarifying key timeframes for the unwinding of Medicaid Maintenance of Eligibility requirements. The guidance is the first since the Consolidated Appropriations Act passed, which decoupled the Medicaid continuous enrollment condition and temporary Federal Medical Assistance Percentage (FMAP) increase from the COVID-19 Public Health Emergency. The continuous enrollment requirement now is scheduled to end March 31, 2023, and the FMAP increase will be gradually phased down beginning on April 1, 2023, and will end completely on Dec. 31, 2023. According to the guidance, states must begin submitting certain documentation to CMS regarding their plans for redeterminations starting in Feb. 2023 and will be subject to reporting requirements beginning April 1, 2023.

The requirements are intended to ensure redeterminations are being conducted in such a way that minimizes beneficiary burden and promotes continuity of coverage while maximizing state effectiveness. States who fail to comply with these new reporting requirements will face possible reductions to their FMAP. CMS plans to meet individually with each state Medicaid director and issue additional guidance. A timeline of key dates regarding the unwinding of continuous enrollment requirements can be found on page 5 of the guidance. View a state-by-state unwinding tracker from the Georgetown University Health Policy Institute. 

Due to AMA advocacy and outreach to the Centers for Medicare & Medicaid Services (CMS), CMS has extended the deadline to file a 2022 MIPS Extreme and Uncontrollable Circumstances (EUC) hardship exception until March 3, 2023. The original deadline was Jan. 3, 2023. If physicians feel they have been impacted by the COVID-19 pandemic in 2022, they may file a MIPS hardship exception with CMS to avoid a 2024 MIPS penalty.  

The AMA is glad to see CMS recognize the toll the pandemic continues to have on physician practices by providing additional time to file a hardship exemption from the 2022 MIPS program. The AMA encourages practices to take advantage of this administrative relief. For more information on how to file an EUC, please see the CMS website.

The U.S. Secretary of Health and Human Services, Xavier Becerra, renewed the COVID-19 public health emergency (PHE) declaration, effective Jan. 11. The PHE will remain in effect for at least another 90 days. Secretary Becerra re-committed to providing no less than 60 days' notice prior to the termination of the COVID-19 PHE.