August 27, 2015

National Update

CMS discovers PQRS data errors

The Centers for Medicare & Medicaid Services (CMS) recently announced that various errors were discovered in the 2014 Physician Quality Reporting System (PQRS) data submitted by vendors on behalf of physicians and group practices that reported via electronic health records (EHR) and qualified clinical data registries (QCDR). Physicians who participated and reported in 2014 PQRS through claims and clinical registries are not affected.

Because of the errors, the EHR and QCDR data is inconsistent and cannot be used to calculate quality performance for the 2016 value modifier, nor can PQRS performance information be included on Physician Compare. For PQRS and the meaningful use EHR incentive programs, there is no impact because physicians are judged on whether they successfully reported rather than on their actual performance—simply receiving the data will allow CMS to deem a physician or group practice as successful for purposes of avoiding a payment adjustment in 2016 or for receiving a 2014 incentive. There will be no need for physicians or group practices to submit a PQRS informal review request.

For the value modifier, which involves calculating actual quality scores in addition to determining whether quality measures were reported, CMS has acknowledged the vendor data errors may create problems. Specifically, CMS will not be able to accurately calculate the PQRS portion of the Quality Composite Score. Instead, the score will be based solely on the claims-based outcomes measures and Consumer Assessment of Healthcare Providers and Systems Survey, if applicable.

The AMA will provide additional information as it is available.

2014 PQRS quality measures may be publicly reported

For the first time, the Centers for Medicare & Medicaid Services (CMS) will publicly display a subset of individual 2014 PQRS measures through star ratings on physicians’ individual profile pages in late 2015. Since 2014, CMS has publicly reported PQRS quality information on group practices participating under the group practice reporting option through star ratings.

In response to AMA advocacy, CMS will only report information through star ratings on physicians and group practice that were successful with 2014 PQRS. Physicians and group practices will also have the opportunity to review the information before it goes live and flag problematic information. The preview period will last 30 days and is expected to start Oct. 5. In order to review a preview report, a physician will have to access the report through the PQRS Portal and have an EIDM account.

The AMA will continue to advocate for a longer preview period and ensure that displayed information is accurate and statistically valid and reliable.

CMS will host three one-hour webinars where physicians and stakeholders will have the opportunity to ask questions about public reporting on Physician Compare and the 2014 quality measure preview period. All sessions will present the same information and will be offered at:

Register today for a session.

AMA to DEA: Flexibility in e-prescribing controlled substances needed

Although many physicians are already e-prescribing non-scheduled medications, take-up rates for electronic prescribing of controlled substances have been very low, likely because of barriers imposed by interim U.S. Drug Enforcement Administration (DEA) regulations. The DEA recently reached out to the AMA seeking input on future rulemaking aimed at updating and improving the regulations on electronic prescribing of controlled substances.

In a follow-up letter to the DEA (log in), the AMA reinforced the need for the DEA to provide greater flexibility for electronic prescribing of controlled substances, particularly around prescriber identity proofing and authentication. For example, the AMA recommends that the new DEA rules allow lower-cost, high-performing biometric devices, such as fingerprint readers on laptop computers and mobile phones, to be used for authentication. The AMA will continue to press the DEA to significantly reduce the barriers for e-prescribing of controlled substances.

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State Update

Montana and Massachusetts launch Rx abuse education campaigns

Medical societies in Montana and Massachusetts recently launched new websites to help educate physicians and the public about prescription drug abuse.

The Montana Medical Association’s (MMA) “Know Your Dose” website includes resources such as a no-cost educational module and a health care provider toolkit. The MMA launched the effort in a statewide effort with MMA leadership and Montana Attorney General Tim Fox. The initiative continues with the development and airing of public service announcements with rural radio air time donated by a local legislator.

The Massachusetts Medical Society’s (MMS) “Smart and Safe” campaign includes resources for prescriber education, patient information, medication storage and disposal. The MMS also is making several educational resources available at no cost to Massachusetts physicians, including courses on managing pain without overusing opioids, legal implications for identifying drug dependence, managing risk when prescribing narcotics, and principles of palliative care and persistent pain management.

The MMS also has teamed up with the New England Patriots to develop radio spots that will air before, during and after the Patriots games, and will also air during the week in Boston.

For more information about the MMA and MMS efforts, email MMA Executive Director Jean Branscom and MMS Chief Digital Strategist and Communications Director Frank Fortin.

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Judicial Update

Ruling could give insurers more leeway to terminate physicians

The outcome of a recent case could have implications for other physicians and their patients as a federal court decided it was permissible for a large health insurer to terminate two physicians from its network following a dispute over the necessity of medical services they provided.

In Rojas v. Cigna Health and Life Insurance Company, two New York physicians and their medical practice sued Cigna after the health plan decided it should not have paid the physicians for certain allergy tests, arguing that the tests the physicians had ordered weren’t in line with its coverage policies. Cigna asked the plaintiffs to return the alleged overpayments and said it would terminate the physicians from its network.

The physicians said they could not be terminated because they should be considered plan beneficiaries under the Employee Retirement Income Security Act (ERISA) based on assignment of benefits by their patients. ERISA prohibits discrimination against beneficiaries who exercise rights made available under employee benefit plans.

While the physicians contended that they were beneficiaries by virtue of signed assignment-of-benefit forms, the court said these forms only would transfer patients’ rights to be paid by Cigna. Under this interpretation, the “benefit” can only belong to patients.

Because the plaintiffs were not seeking payment, ERISA did not apply, the court ruled.

The court also criticized the outcome of another recent ERISA-related case, Pennsylvania Chiropractic Association v. Independence Hospital Indemnity Plan, Inc., which did hold that payments to health care professionals would make these professionals “beneficiaries” within the meaning of ERISA.

The Litigation Center of the AMA and State Medical Societies, along with the Medical Society of the State of New York, backed the physician plaintiffs and filed an amicus brief supporting a rehearing of this case. The brief points out numerous cases in which other courts have concluded that “benefit” under ERISA means monetary payment, not medical care.

“[The decision] threatens the ability of providers ever to assert any ERISA claim, even if the provider is designated by the plan and an insured as entitled to benefit payments,” the brief said. “That conclusion is contrary to virtually every other circuit court decision addressing providers’ rights to bring claims under ERISA.”

Read more about cases related to ERISA on the Litigation Center Web page.

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Other News

Strategies to increase health care price transparency

A new AMA policy brief (log in) outlines the need for increased price transparency to address health care costs, including a series of specific measures to expand the availability of health care pricing information.

The brief reflects policy adopted at the 2015 AMA Annual Meeting, which states that the successful implementation of any price transparency program will require cooperation and collaboration by all stakeholders. Better price transparency would allow patients and their physicians to make value-based decisions when patients have a choice of provider or facility.

The policy, based on a report from the AMA Council on Medical Service, calls for:

Attend Candidate Campaign School in Las Vegas

Every year, physicians facing crises in medical liability, payment and scope of practice realize that involvement in the political process is no longer a luxury—it is a necessity. That’s why dozens of physicians and their spouses seek public office, or work to help elect other friends of medicine across the country.

You can become an advocacy expert with the Candidate Campaign School, hosted by AMPAC and the Nevada State Medical Association and Clark County Medical Society. Physicians, spouses of physicians, residents and medical students can attend the school, Sept. 25-26 in Las Vegas.

Political experts will offer advice about politics and the hurdles candidates must overcome to mount a competitive campaign. Attendees will learn:

Attend this seminar to get answers to your questions and determine if running for public office is for you. Those who are members of the AMA, Nevada and Clark County medical societies can attend for free. Out-of-town participants can attend for $150, and receive a 50 percent discount if they are members of their state or county society. Register to attend.

The AMA designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Upcoming Events

Voice your concerns: While most physicians have adopted electronic health records, usability issues have made them burdensome, and many physicians haven’t been able to meet meaningful use requirements. Share your story online, watch a video of real physicians discussing their own issues with the program and email your members of Congress at

Feb. 19-21:
Sign up for the 2016 AMPAC Candidate Workshop, which prepares those considering a run for public office. For more information or to apply, please see the online registration form or email Jim Wilson of the AMA.

April 13-17:
Register for the 2016 AMPAC Campaign School, which is for AMA members who wish to become involved in the political process as advocates and volunteers for medicine-friendly candidates. For more information or to apply, please see the online registration form or email Jim Wilson of the AMA.

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