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News & Features

Work RVU Calculator Developed

Most employed physicians have contracts that require them to bill a minimum number of work RVUs in a year. Physicians don’t have any way to know how many RVUs they produce or how to maximize their RVUs.

The calculator was developed by Harris County Medical Society and is available to all IMS Members. The physician selects their specialty and a monthly, quarterly or yearly time period. A spreadsheet of the most common CPT codes in their specialty is shown.

Enter the number of times you perform each CPT code and the spreadsheet calculates your total work RVUs.

To view the link, please click here.

MACRA Final Rule Background

Here are two documents prepared by the AMA’s Washington Office, outlining major provisions of Medicare’s new Quality Payment Program (QPP) for physicians that was created by the Medicare Access and CHIP Reauthorization Act (MACRA). The longer summary document provides some detail of the various components of the final rule that was issued last week, and notes where key improvements were made to the policies set forth in the original proposed rule. The second is a chart with more abbreviated descriptions of changes to the original proposed rule that were secured. Additional material is in the process of being developed by the AMA.

QPP Summary

QPP Highlight Chart

Seamless Conversion to Medicare Advantage

Some questions have been raised about recent press coverage on plans enrolling new Medicare beneficiaries in Medicare Advantage without the beneficiary’s knowledge. The American Medical Association (AMA) raised concerns and a number of questions with senior officials at the Centers for Medicare and Medicaid Services (CMS). Below are CMS’ answers. CMS officials have informed us that in the near future they intend to provide additional information on questions 4 and 5, and we will send that to the Federation as soon as we receive it. It is our understanding that this policy was developed a number of years ago by Congress and pre-dates Medicare Advantage. The intention was to ease the pathway for low-income people with disabilities who were covered by Medicaid to remain in their same plan as they became dually eligible for Medicaid and Medicare, due either to their disability or their age. Clearly, the policy is now having an impact on patients in commercial or exchange plans, and it is apparent from the CMS responses below that the agency’s policies are still evolving to address the unintended consequences of the policy. However, outside of few anecdotes and the beneficiary highlighted in the articles we are unaware of other similarly affected beneficiaries.

If you have information regarding additional beneficiaries please let me know. The AMA will remain engaged with CMS as this issue develops.

Q1: Is there an HPMS memo or guidance to the plans that spells out the procedures they need to follow to avoid cherry-picking and ensure patients are making informed decisions about opting out or not?

A: MA organizations are required to follow the guidance in Section 40.1.4 of Chapter 2 of the Medicare Managed Care Manual, which can be found here.

Q2: Is there guidance to the regional offices on what to look for in the plans’ proposals to do these conversions?

A: An MA organization’s proposal must address all the seamless conversion enrollment requirements outlined in CMS guidance.

Q3: Are there safeguards in place to prevent cherry-picking?

A: CMS guidance requires the MA organization to include all individuals in the health plan who are approaching initial Medicare eligibility, regardless of whether eligibility is based on disability or age.

Q4: Do the plans need to provide info to CMS about how their MA plan networks compare to their commercial or Medicaid networks, or info to the patients about how the networks differ?

A: CMS requires that information on the MA plan network be provided to new enrollees prior to the new coverage effective date. Such requirements are outlined in both Section 40.4 of Chapter 2 of the Medicare Managed Care Manual, and in Section 30.7 of the Medicare Marketing Guidelines, the latter of which can be found here. This enrollment mechanism does not currently require that comparative information between the non-Medicare plan and the MA plan be provided to individuals being offered seamless conversion enrollment. We are continuing to evaluate ways to improve the seamless conversion process for beneficiaries and this is one aspect we will focus on.

Q5: Is there any info you can share yet?

A: CMS will soon be sharing more information on the plans that have been approved for the seamless conversion enrollment mechanism. This information will be posted publicly on the Medicare Managed Care Eligibility and Enrollment webpage found here.

Q6: Are these proposals from the plans reviewed by the ROs and, if so, what are they supposed to look for?

A: The proposals are reviewed by the CMS Regional Offices, with consultation by CMS Central Office. An MA organization’s proposal must address all the seamless conversion enrollment requirements outlined in CMS guidance. This includes an explanation on how the MA organization can identify both aged and disabled individuals in their non-Medicare product line(s) 90 days before Medicare eligibility, what outreach activities the MA organization will take to inform the individual of the seamless conversion (minimum must include a written notice at least 60 days prior to effective date) and ability to opt out, how the plan will process opt out requests, and the organization’s acknowledgement that they will submit the enrollment transaction to CMS at least 60 days prior to the effective date.

40.1.4 - Seamless Conversion Enrollment Option for Newly Medicare Advantage Eligible Individuals

MA organizations may develop processes to provide seamless enrollment in an MA plan for newly Medicare Advantage eligible individuals who are currently enrolled in other health plans offered by the MA organization (such as commercial or Medicaid plans) at the time of their conversion to Medicare. CMS will review an organization’s proposal and must approve it before use. MA organizations must send proposals to the appropriate Regional Office account manager and must meet the following conditions.

Important Reminder about Billing Requirements for Certain Dual-Eligibles

As part of the AMA’s ongoing work with the Centers for Medicare & Medicaid Services on issues affecting Medicare providers and beneficiaries, the AMA would like to remind physicians that balance billing is prohibited for Medicare beneficiaries enrolled in the Qualified Medicare Beneficiary (QMB) program. CMS has conveyed their concern that some physicians are still billing QMB beneficiaries, despite the existing prohibition. The QMB program is a Medicaid program that helps very low-income dual eligible beneficiaries—e.g., individuals who are enrolled in both Medicare and Medicaid—with Medicare cost-sharing. Beneficiaries in the QMB program have annual incomes of less than $12,000. Federal law protects QMBs from any cost-sharing liability and prohibits all original Medicare and Medicare Advantage providers—even those who do not accept Medicaid—from billing QMB individuals for Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments that physicians receive for furnishing services to a QMB individual are considered payment in full. It is important to note that these billing restrictions apply regardless of whether the state Medicaid agency is liable to pay the full Medicare cost-sharing amounts (federal law allows state Medicaid programs to reduce or negate Medicare cost-sharing reimbursements for QMBs in certain circumstances). Physicians may be subject to sanctions for failing to follow these billing requirements, and CMS has indicated that they may start conducting more frequent audits to address this practice.

For further information, see MLN Matters, Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program.

HHS Announces $100 Million to Support Small Practices

The Medicare Access and Chip Reauthorization Act of 2015 (MACRA) contained a provision to fund on-the-ground training and education for Medicare clinicians in solo or small group practices of 15 clinicians or fewer. The U.S. Department of Health and Human Services (HHS) is required to award $20 million each year over the next five years for a total of $100 million to support small practices transitioning to the quality payment program.

The funds will help provide technical assistance to small practices—especially those in rural and medically underserved areas, as well as those in areas with health professional shortages. The AMA has been pressing HHS to release these funds.

Organizations can apply to receive funding for our efforts to support physicians in this process. To be eligible, organizations must be able to tailor training to clinicians and provide this education to them free of charge.

Learn more about the recent announcement and how to apply.

What to do When the DEA Visits and Demands you Surrender your Registration

ISMA e-Reports, Aug. 10, 2015, By J. Richard Kiefer, JD, Bingham Greenebaum Doll LLP Courtesy of ISMA

You are busy seeing patients when your receptionist interrupts you to tell you there are two U.S. Drug Enforcement Administration (DEA) agents in the lobby to see you. They show their badges and credentials and tell you they’ve come to inspect your controlled substance prescriptions and ask some questions. Click here for further information.

IMS Commentary: Getting Needed Care

Many patients see physicians or have procedures and then feel like they are being cheated or are extremely disappointed because they get a bill that they expected their insurance company to cover. Why does this happen?

Patients receiving health care services need to be aware of what is occurring behind the scenes as physicians and others work to give patients care that is needed and the best available.

Click here to read the attached release for the “IMS Commentary: Getting Needed Care.”

Insurance Complaint?

Are you having a problem with poor-quality MRIs or other tests as a result of an insurance company phoning patients with a lower cost option? The Insurance Commissioner has a great response regarding this type of complaint. Always contact the Insurance Commissioner with similar insurance company complaints. The complaint form is located here.

Talent Gallery

The IMS wants to feature the creative talents of our Members. Please send your photographs or images of your creative work to for posting on our Talent Gallery and for use in the IMS Bulletin and other publications.