Biden Administration Outlines Next Steps Following Surprise Billing Ruling in Texas
By Marty Stempniak | March 2, 2022
The Biden administration is detailing next steps after physicians recently scored a “major victory” in court over legislation to address surprise medical bills.
A Texas judge last week struck down one key provision of the No Surprises Act, governing how out-of-network payment disputes are settled between payers and providers. In an update shared Monday, the administration said it is now reviewing the decision and contemplating what comes next.
The Departments of Health and Human Services, Labor and Treasury said they’re taking several actions to conform with the Texas court’s order. Those include withdrawing guidance related to the part of the rule that has been invalidated and providing training to certified independent dispute-resolution entities on the changes.
“This court’s order did not affect any of the departments’ other rulemaking under the No Surprises Act,” according to the Feb. 28 update. “Thus, consumers continue to be protected from surprise bills for out-of-network emergency services, out-of-network air ambulance services, and certain out-of-network services received at in-network facilities.”
To read more, go to Radiology Business.
CMS to Reweigh MIPS Data for Some Physicians Amid Pandemic
By Lisa Gillespie | March 1, 2022
The Centers for Medicare and Medicaid Services is giving physician groups participating in its Merit-based Incentive Payment System more time to apply for an extreme and uncontrollable circumstance waiver so that 2021 quality data has less of a chance of negatively impacting their payments.
Physician groups, virtual groups and alternative payment model entities can apply for a waiver until March 31, and if granted, will have their data re-weighted to account for COVID19 impacts. In addition, if physician groups didn’t submit data, they will not receive a penalty. The previous deadline was on Dec. 31, 2021, but the American Medical Association and others argued that physician groups needed an extension.
“The increase in COVID cases — and increased demands — coincided with the original E&C hardship application deadline at the end of 2021,” said Dr. Gerald E. Harmon, president of the American Medical Association. “As a result, physicians might have missed the opportunity to file for a hardship application and faced a payment adjustment, and the re-opening of the 2021 application period will give physicians, including APM participants, much-needed relief and better ensure they avoid a negative 2023 MIPS payment adjustment.”
The move comes after the agency provided individual physicians with an automatic exemption in November 2021.
Congress established MIPS in 2015 with the intention to improve outpatient outcomes and reduce spending. Providers can pick from a range of measures. Of the1 million clinicians who participated in MIPS’ first year in 2017, 93% received bonuses that were applied in 2019. About 5% of providers received penalties that capped at 4%.
CMS’ decision may signal how they will treat hospital quality and safety data from 2021. The agency waived requirements to submit for 2020, but has remained silent on 2021, when the pandemic hit health systems with additional COVID-19 waves.
To read more, go to Modern Healthcare.
HHS to Distribute $560 in Phase 4 COVID-19 Provider Relief Funds
By Victoria Bailey | February 28, 2022
HHS is distributing another $560 million in Provider Relief Fund Phase 4 payments to over 4,100 healthcare providers that have been affected by the COVID-19 pandemic.
Provider Relief Funds have been crucial to supporting healthcare providers as they continue to care for patients during the pandemic.
Following this new round of funding, the Health Resources and Services Administration (HRSA) has allocated nearly $11.5 billion of the promised $17 billion Phase 4 general distribution payments to more than 78,000 providers across the country. HRSA has distributed almost $7.5 billion in American Rescue Plan Rural payments to more than 44,000 providers since November 2021.
“Provider Relief Funds have been a lifeline for healthcare providers across the country,” HHS Secretary Xavier Becerra said in the announcement. “From providing life-saving care to tackling workforce challenges, these funds will help many healthcare facilities weather the pandemic’s continued impact. The Biden-Harris Administration will continue to ensure our providers have the necessary support and tools to keep our families safer and healthier.”
HHS announced it would make this fourth round of Provider Relief Payments in September 2021. The department is focusing on equity with this phase of funding and prioritizing smaller providers who have faced financial difficulties. To receive funds, providers must demonstrate revenue losses and expenses associated with the COVID-19 pandemic between July 1, 2020, and March 31, 2021.
Additionally, providers who serve Medicaid, Children’s Health Insurance Program (CHIP), and Medicare beneficiaries will receive bonus payments.
“Healthcare providers have continued to lead the fight against COVID-19 from the frontlines,” HRSA Administrator Carole Johnson stated in the announcement. “The Provider Relief Fund is an important resource in helping to support this work and sustain health services and the dedicated health care workforce across the country.”
Around 86 percent of the Phase 4 applications have been processed, HHS said. The department will process the remaining applications throughout early 2022.
HHS distributed the first batch of Phase 4 payments in December 2021. Around 69,000 providers received $9 billion in funds.
During the second round, more than $2 billion was distributed to around 7,600 providers across the country.
So far, providers in California and New York have received the highest payment amounts during Phase 4 of the Provider Relief Funds, collecting respective totals of $1.4 billion and $1.1 billion.
To read more, go to RevCycle Intelligence.
ACR Outlines Changes in Medicare Lung Cancer Screening Coverage
By Dave Fornell |February 28, 2022
The American College of Radiology recently released a detailed summary of the National Coverage Determination related to screening for lung cancer with low dose computed tomography.
ACR’s summary outlines finalized changes in response to more than 200 public comments received by the Centers for Medicare & Medicaid Services. CMS released its final decision following a formal joint request, submitted in March 2021 by the ACR, GO2 Foundation for Lung Cancer, and the Society of Thoracic Surgeons. Additional comments by the ACR and these organizations were submitted in June and December 2021, and CMS announced the final coverage decision Feb. 10.
The agency said its decision expands coverage for lung cancer screening with changes that make it easier for imaging centers to participate and includes younger patients under the new rules.
“Expanding coverage broadens access for lung cancer screening to at-risk populations,” CMS Chief Medical Officer and Director of the Center for Clinical Standards and Quality Lee Fleisher, MD, said in a statement about the changes. “The decision not only expands access to quality care but is also critical to improving health outcomes for people by helping to detect lung cancer earlier.”
Several changes in Medicare coverage of CT lung cancer screening in 2022
The three big changes include:
• Beneficiary eligibility criteria
• Counseling and shared decision-making visit
• Reading radiologist and radiology imaging facility eligibility criteria
To read more, got to Radiology Business.
Duke Estimates 15% of Breast Cancer Cases Overdiagnosed, Less Than Previously Thought
By Lisa Gillespie | February 28, 2022
One in seven women who are diagnosed with breast cancer after a mammogram with no previous symptoms are overdiagnosed and likely overtreated, according to a new estimate from researchers at Duke University.
The new estimate published in the Annals of Internal Medicine on Monday provides doctors and their patients a closer estimate of how likely women will end up dying of other causes than their diagnosed breast tumors.
“The real harm comes in this: every woman with breast cancer gets a lot of pretty harmful invasive treatments, and for a woman with overdiagnosed breast cancer, it’s all for naught,” said Marc D. Ryser, lead author and assistant professor in the department of population
health sciences at Duke University. “She does not derive any benefit, because she would never have known about it, and she would have died with it, but not from it. She was made a cancer patient for no reason.”
The study has long been in the works, following research published ten years ago that found 25% of all breast cancers found through a mammogram were overdiagnosed. Other previous estimates of overdiagnosis ranged up to 54%.
The Duke study’s estimated 15.4% overdiagnosis rate is the first step in providing clinicians with information that will help patients make more informed decisions about their treatment, according to Ruth B. Etzioni, a biostatistician and professor in the Public Health Sciences Division at Fred Hutchinson Cancer Research Center.
“The frontier of really dialing down treatment is where it’s at right now,” Etzioni said, adding that their estimate is an average, and does not take into account the overall health of a woman, the type of tumor or other factors that should influence decision making. “There is no good predictive model for that progression.”
The researchers from the study are working on such a model. Other authors are also conducting a randomized trial that is monitoring the outcomes of women with early, low-risk breast cancer and their treatment decisions.
The overdiagnosis rate increased from 11.5% at the first screening at age 50, to 23.6% by the last screening at age 74. The researchers used the records of 35,986 women part of the Breast Cancer Surveillance Consortium, which collected information based on mammography facilities and other data sources between 2000 and 2018. The median age at first screening was 56, and on average women received 2.3 screenings, which totaled 82,677 mammograms. A total of 718 breast cancers were diagnosed, including 80% that were invasive, and almost 20% that were in the very earliest stages.
Under current U.S. guidelines, mammograms should be optional for women aged 40 to 44, and then done annually from ages 45 to 54. Women 55 and older are then switched to biannual, and can continue until they have a life expectancy of less than a decade left. Mammograms have also increased in cost over the years as new technology is introduced.
To read more, go to Modern Healthcare.
Several Medical Imaging Societies Ask to be Involved in Congressional Medicare Reform Efforts
By Dave Fornell | February 25, 2022
Numerous medical imaging societies were among about 100 healthcare groups that signed onto a letter sent to Congressional leaders Feb. 25 that requests collaboration as legislators work to reform the Medicare physician payment system.
Among the medical imaging related societies that signed the letter included the American College of Radiology (ACR), Radiology Business Management Association (RBMA), Society of Interventional Radiology (SIR), Society of Nuclear Medicine and Molecular Imaging (SNMMI),
American Society for Radiation Oncology (ASTRO), American Society of Echocardiography (ASE), American Society of Nuclear Cardiology (ASNC), and the Association for Quality Imaging. In total, the organizations that signed on to the letter represent more than 1 million physician and nonphysician healthcare clinicians.
“We respectfully request that your committees collaborate with the provider community to immediately initiate formal proceedings (hearing, roundtables, expert panels, etc.) to discuss potential reforms to the Medicare physician payment system to ensure continued beneficiary access to care,” the societies requested in the letter.
The societies said they appreciated Congress’ actions over the past several years to mitigate scheduled cuts to the Medicare Physician Fee Schedule (MPFS). But, the letter states systemic issues, such as the negative impact of the Medicare physician fee schedule’s budget neutrality requirements and the lack of an annual inflationary updates to payments, continue to generate significant instability for clinicians moving forward. The societies said this threatens beneficiary access to essential healthcare services. The COVID-19 pandemic has also compounded these existing issues, the societies added.
Other challenges cited include the Medicare Access and CHIP Reauthorization Act’s (MACRA) Quality Payment Program (QPP), which have prevented most clinicians from meaningfully participating in the program.
“Nonphysician clinicians are still not fully integrated in the Merit-Based Incentive Payment System (MIPS) because most are ineligible to report cost and promoting interoperability measures, which account for 55% of MIPS scoring,” the letter to Congress stated. “The incentive payments have also been historically low, far below the 9% Congress intended, rendering them an ineffective mechanism to offset the reductions required by budget neutrality.”
Under the current payment system, many clinicians continue to face steep annual reductions in their Medicare payments, the letter stated. This has largely been due to the inherent instability of the MPFS, coupled with the shortcomings of MACRA’s QPP, which the societies said has created an environment where many practices have seen their payments decrease year-over-year. This decrease in payments has also been compounded by increasing costs and growing inflation.
To read more, go to Radiology Business.