Advocacy News

ASE Advocacy Update: CMS Interoperability and Prior Authorization Final Rule

ASE has been working to fight prior authorization on behalf of our members and joined several coalitions, including the Alliance of Specialty Medicine, to advance this issue. There has been progress with Centers for Medicare & Medicaid Services (CMS) action today! The CMS Interoperability and Prior Authorization Final Rule has been finalized. The rule sets requirements for Medicare Advantage (MA) organizations, Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) offered on the Federally-Facilitated Exchanges (FFEs), to improve the electronic exchange of health information and prior authorization processes for medical items and services. Most of these changes will take effect in 2026.

Please see the CMS press release for more information, https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process

The fact sheet for this final rule is available here: https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f

New AMA Survey to Document Changes in Physician Practice Expense

Your input will ensure future accurate valuation!

The American Medical Association (AMA) is undertaking a new national survey, supported by 173 healthcare organizations, to collect representative data on physician practice expenses. The aim of the Physician Practice Information (PPI) Survey is to better understand the costs faced by today’s physician practices to support physician payment advocacy. The study will serve as an opportunity to communicate accurate financial information to policymakers, including members of Congress and the Centers for Medicare & Medicaid Services (CMS). The AMA has contracted with Mathematica, an independent research company with extensive experience in survey methods as well as health care delivery and finance reform, to conduct the study.

Watch for invitations to complete this survey in your email inbox (remember to check spam/junk folders):

Invitations and reminders about the survey will come from PPISurvey@mathematica-mpr.com with the subject line: “American Medical Association requests your input on physician practice expense and patient care hours.“
Invitations and reminders about physician hours worked will come from PhysicianHoursSurvey@mathematica-mpr.com with the subject line: “Please help to update accurate physician payments.“

The Medicare physician payment schedule, maintained by CMS and used by many other payers, relies on 2006 cost information to develop practice expense relative values, the Medicare Economic Index and resulting physician payments. As the U.S. economy and health care system have undergone substantial changes since that time, including inflation and the wide-spread adoption of electronic health records and other information technology systems, practice expense payments no longer accurately reflect the relative resources that are typically required to provide physician services.

The survey will rely on financial experts in the practice to complete an online financial information survey. The number of direct patient care hours is a critical component of the Medicare payment methodology. Therefore, thousands of individual physicians will receive a short patient care hours survey from either their practice directly or from Mathematica. The input from physician practices and individual physicians that are randomly selected to participate in this study is critical for its success. Participation will ensure that practice expenses and patient care hours are accurately reflected.

Please contact sherry.smith@ama-assn.org with any questions related to the PPI Survey or Irene Butler ibutler@asecho.org if you would like additional background information.

Mathematica formally launched the PPI Survey on July 31, 2023.

ASE Advocacy Update 9/29/23

The fall season brings with it the potential for government shutdown on October 1. We are seeing this play out this week as Congress has yet to pass any of the 12 FY2024 appropriations bills or a short-term spending bill (i.e., Continuing Resolution (CR)) to keep the government funded while Congress continues to work on a broader spending package. The Senate is expected to vote by Saturday on a CR that would fund the government until November 17. There are two CR proposals in the House—one to fund the government for 30 days and the other until January 11—but a vote has not been scheduled and may not be by the October 1 deadline. Below are some highlights of the impact on key health policy areas in the event Congress does not pass a CR by midnight Saturday, September 30, and there is a government shutdown.

Congress

Congressional offices will remain open.

Medicare and Medicaid

The Centers for Medicare & Medicaid Services (CMS) will continue to process claims.
Physicians would not have to hold claims until the CR passes, but there could be a delay in payment if the shutdown is prolonged and funding to Medicare Administrative Contractors is delayed.
If the shutdown is prolonged, it is possible that the release of the Medicare physician fee schedule final rule, outpatient prospective payment system final rule, and other major regulations could be delayed.
Medicare benefits will not be affected.
Medicaid has full funding for the next three months.
Approximately half of CMS employees would be deemed essential and continue to work, although many would be unpaid until the shutdown ends.
CMS staffing levels may not be sufficient to respond to physicians’ questions about Medicare policies or scores under the Merit-based Incentive Payment System (MIPS).
Center for Medicare and Medicaid Innovation (CMMI) staff may continue to develop new alternative payment models, but any new model that CMMI plans to formally announce would likely be delayed.

Department of Health and Human Services (HHS)

HHS will use its authority under the Antideficiency Act (ADA) to maintain existing HHS activities, including research and vaccine and therapeutic development.
CMS will maintain the staff necessary to make payments to eligible states for the Children’s Health Insurance Program (CHIP).
CMS will continue Federal Exchange activities, such as eligibility verification, using Federal Exchange user fee carryover.
The Substance Abuse and Mental Health Services Administration (SAMHSA) will continue substance abuse and mental health programs, including those that provide critical behavioral health resources in the event of a natural or human-caused disaster such as Disaster Behavioral Health response teams, the 24/7 365 day-a-year Disaster Distress Helpline that provides crisis counseling to people experiencing emotional distress after a disaster, and the 988/Suicide Lifeline to connect people in crisis with life-saving resources.
The Administration for Strategic Preparedness and Response (ASPR) will maintain the minimal readiness for all hazards, including COVID-19, pandemic flu, and hurricane responses.
The National Institutes of Health (NIH) will continue research and clinical activities.
The Food and Drug Administration (FDA) will continue to support drug and medical device reviews, as well as emergency use authorizations and countermeasures to fight the COVID-19 pandemic. FDA will also continue core functions to handle and respond to emergencies, such as monitoring for and quickly responding to outbreaks related to foodborne illness and the flu, supporting food and medical product recalls when products endanger consumers and patients, pursuing criminal and certain civil investigations when the public health is at risk, and screening the food and medical products that are imported to the U.S.
HHS will continue to protect human life and property, such as monitoring for disease outbreaks conducted by the Centers for Disease Control and Prevention (CDC).
CMS regulations and guidance related to the No Surprises Act, including the Independent Dispute Resolution process, could be delayed.
The Health Resources and Services Administration (HRSA) will continue to oversee many direct health services and other activities funded through carryover balances, such as the Ryan White HIV/AIDS program – Parts A and B and Ending the HIV Epidemic.
The Agency for Healthcare Research and Quality (AHRQ) will continue activities funded through the Patient-Centered Outcomes Research Trust Fund (PCORTF).
Advanced Research Projects Agency for Health (ARPA-H) is under a three-year appropriation; all of ARPA-H activities would continue during a lapse of appropriation.
The Indian Health Service (IHS) is under advance appropriations for FY 2024; the majority of IHS-funded programs will remain funded and operational in the event of a lapse of appropriation.

Miscellaneous

Supplemental Nutrition Assistance Program (SNAP) will continue at least through October.
The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) could begin an immediate reduction in benefits a few days after the shutdown starts, although some states may be able to use extra funding to maintain funding for a week or two.
Student loan payments: The beginning of a government shutdown could coincide with the restart of federal student loan payments in the U.S. on Oct. 1, but borrowers will still have to make payments to their loan service providers.

Urgent Call to Action – Support ASE Representation on Vital Issues by Joining the AMA!

ASE is working hard to ensure your voice is heard on issues related to legislative matters, regulatory issues, coding and reimbursement. To do so, ASE must maintain the Society’s seat in the American Medical Association (AMA) House of Delegates. To qualify, 25% of ASE’s U.S. physician members must also be members of the AMA.

As a member of the House of Delegates, ASE:

Helps sets the legislative and regulatory priorities for the AMA.
Has full delegate status which provides ASE with full representation before CPT/RUC.
- This has contributed to some of ASE’s more recent, substantial advocacy successes.

For more detailed information please read: The ABC’s of Payment for Cardiovascular Ultrasound Services and Why the AMA Matters .

To help ASE reach this critical goal, click here.

We urge you to join the AMA today to help us ensure that echo has a voice!

CMS PFS and HOPPS Final Rules

On November 1, 2022, the Centers for Medicare & Medicaid Services (CMS) released the CY 2023 Revisions to Payment Policies Under the Physician Fee Schedule (PFS) and Other Revisions to Medicare Part B [CMS-1770] Final Rule, which includes final policies related to Medicare physician payment and the Quality Payment Program (QPP). In addition, CMS released the calendar year (CY) 2023 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems Final Rule [CMS-1772-FC], finalizing payment rates and policy changes affecting Medicare services furnished in hospital outpatient and ambulatory surgical center (ASC) settings for CY 2023.

PFS Overview

Conversion Factor

The final 2023 Medicare conversion factor (CF) is $33.06, reduced from the 2022 final conversion factor of $34.61. The final rule establishes a 4.47% cut to physician payments under the 2023 fee schedule unless Congress can pass legislation that would offset or mitigate this reduction in payment.

Stakeholders, including ASE, have advocated for an improvement over the proposed rule’s 4.47% reduction to the CF, but the final rule’s methodology resulted in a slight decrease. The update is based on several factors: a statutory 0% update scheduled for the PFS in CY 20231 and a funding patch passed by Congress at the end of CY 2021 through the Protecting Medicare and American Farmers from Sequester Cuts Act. This bipartisan legislation partially mitigated a 3.75% cut to the CY 2022 CF and staved off other Medicare cuts, including a phased-in delay of the Medicare sequestration and pay-as-you-go cuts. The 3% payment patch was only in effect for 2023 and the Medicare sequestration relief was phased out starting April 1, 2022. The overall negative adjustment to the CF for 2023 is driven by the expiration of the 3% payment patch and a statutorily required budget neutrality adjustment due to other spending increases. Additionally, unless Congress acts to further delay additional anticipated cuts arising from pay-as-you-go federal budget requirements, Medicare payments could be cut by an additional 4%.

Physicians are concerned that full relief may not be possible given the significant cost of trying to offset an almost 4.5% cut and numerous competing interests facing Congress in an end-of-year legislative package. ASE will continue to work with a coalition of national and state medical societies in urging Congress to prevent these cuts before January 1, 2023.

Practice Expense

Last year, CMS finalized a proposal to update prices for clinical labor through a four-year transition period that will be completed in 2025. Physician specialties with substantially higher average shares of direct costs attributable to clinical labor are anticipated to see increases in payment from the clinical labor pricing update, while those with lower average shares of direct costs attributable to labor are anticipated to see decreases in payment. During the four-year transition period, clinical labor rates will remain open for public comment. Unfortunately, echocardiography related services did see an increase in the clinical labor RVUs based on the revised calculations.

Although CMS did not propose a methodology for updating future PEs, CMS believes “it is necessary to establish a roadmap toward more routine PE updates.” CMS also opined that indirect PEs would benefit from a data refresh, and signals “[its] intent to move to a standardized and routine approach” to valuing indirect PEs. Unfortunately, CMS notes that it received few direct responses to many of the specific prompts included in its recent request for information and feedback. Most commenters, including ASE, recommended CMS delay any changes to update the indirect PE survey inputs and urged CMS to wait for the American Medical Association (AMA) data collection effort prior to implementing any changes. The AMA indicated it has continued to work on updates and would likely be ready by early CY 2024 with refreshed data. CMS, however, acknowledges comments that refreshed survey data alone would not address all the competing concerns that CMS must account for when allocating indirect expenses, and that the agency may look to supplement or augment survey data with other verifiable, objective data sets in the future, including data sets that are already in the public domain.

Split / Shared Visits

CMS will delay until CY 2024 the split (or shared) E/M visits policy originally scheduled for implementation in CY 2023. For CY 2023 (as in CY 2022) the substantive portion of a visit may be met by any of the following elements:

history
performing a physical exam
making a medical decision
spending time (more than half of the total time spent by the practitioner who bills the visit).

Under this change, echocardiographers furnishing split/shared E/M visits will continue to have a choice of history, physical exam, medical decision making, or more than half of the total practitioner time spent to define the substantive portion, instead of using total time to determine the substantive portion, until CY 2024. The ASE and many other specialties pushed CMS not to implement its new definition of “substantive portion” as more than half of the total visit time and we will continue to advocate against implementation of this policy change.

Merit-based Incentive Payment System (MIPS)

CMS will maintain the CY 2023 MIPS performance threshold at 75 points (same as CY 2022). This impacts the CY 2025 payment year. Please note, CY 2022 is the final year for the “exceptional bonus” for high MIPS scores. While most cardiologists continue to meet the minimum MIPS reporting thresholds, failing to satisfactorily participate in MIPS for the CY 2023 performance year will result in a 9% payment cut in CY 2025.

MIPS Value Pathways (MVPs) are intended to connect activities and measures from the four MIPS performance categories that are relevant to a specialty, medical condition, or a particular population. For the CY 2023 performance period, CMS will add 5 new MVPs to the previously announced 7 MVPs in the program. CMS will also add measures to the existing 7 MVPs.

HOPPS Overview

For CY 2023, CMS applied a productivity-adjusted market basket increase of 3.8% under the Hospital Outpatient Prospective Payment System (HOPPS) and the Ambulatory Surgical Centers (ASC) Payment System. However, CMS applied several budget neutrality and other adjustments, including a significant 3.09 percentage point reduction to account for changes to its 340B drug purchasing policy. After accounting for these adjustments, the CY 2023 HOPPS conversion factor increases by 1.67% over the 2022 value. The ASC conversion factor will increase by 3.88%, a different and more favorable adjustment largely because it is not directly impacted by the 340B-specific budget neutrality adjustment. In continuation of its existing policy, hospitals and ASCs that fail to meet their respective quality reporting program requirements will be subject to a 2% reduction.

Based on the finalized policies, CMS estimates that total payments to HOPPS and ASC providers (including beneficiary cost-sharing and estimated changes in enrollment, utilization, and case-mix) for CY 2023 will be approximately $86.5 billion and $5.3 billion, respectively, for an increase of approximately $6.5 billion and $230 million, respectively, from CY 2022 program payments.

Supervision by Non-Physician Practitioners

CMS further extends supervision authority to non-physician practitioners for select diagnostic services. In 2020, in response to the COVID-19 pandemic, CMS liberalized its regulations to allow certain non-physician practitioners (nurse practitioners, physician assistants, clinical nurse specialists and certified nurse midwives) to supervise the performance of diagnostic x-ray tests, diagnostic laboratory tests and other diagnostic tests paid under the PFS for the duration of the PHE to the extent they were authorized to do so under their scope of practice and applicable state law. In the CY 2021 PFS final rule, CMS further revised its regulations to make the previous revisions permanent and to add certified registered nurse anesthetists to the list of non-physician practitioners permitted to provide supervision of diagnostic tests to the extent authorized to do so under their scope of practice and applicable state law.

CMS has finalized its policy to further revise existing supervision requirements to make clear that nurse practitioners, clinical nurse specialists, physician assistants, certified registered nurse anesthetists and certified nurse midwives may provide general, direct, and personal supervision of outpatient diagnostic services to the extent that they are authorized to do so under their scope of practice and applicable state law.

To view the Final CY 2022 Payment Rates – MPFS and HOPD, please log in to the ASE Member Portal and visit the Advocacy Portal page.

For further information please see:

CMS Final Rules and Fact Sheets

CY 2023 Physician Fee Schedule Final Rule
CY 2023 Physician Fee Schedule Final Rule Fact Sheet

CMS HOPPS/ASC Final Rules and Fact Sheets

CY 2023 HOPPS/ASC Payment System Final Rule
CY 2023 HOPPS/ASC Payment System Final Rule Fact Sheet