July 7, 2016

National Update

New office-based labs reporting requirement

Under a new Centers for Medicare & Medicaid Services (CMS) regulation, some physician office-based labs (POL) will be will required to report private-payer payment rates and the associated volumes of tests performed within a POL. Labs will be required to report this information to CMS once every three years starting Jan. 1.

The AMA encourages all POLs to begin to prepare for reporting now because the initial reporting period will require retrospective reporting on data collected during the first six months of 2016. Learn more in the AMA's summary of the reporting requirements

2015 Open Payments data released to public

Medicare publicly released 2015 Open Payments data June 30. This followed a 45-day period for physicians to review their data and dispute errors that were presumably adjudicated during a data correction period.

Physicians can view their Open Payments data or see how they compare to their peers at CMS' Open Payments website. Visit the AMA website for contextual talking points (log in) that are designed to help physicians respond to general inquiries about their data.

It's not too late for physicians to review their data: The official review and dispute period ended May 15, but physicians can still register to review their data and dispute errors. Unresolved disputes or corrections will be reflected in the next scheduled update of the database. 

Check out the AMA's step-by-step instructions on how to register and review Open Payments data.

Back to Top

Issue Spotlight

Key changes recommended for the new Medicare payment system

Physicians have submitted comments to the Centers for Medicare & Medicaid Services (CMS), detailing the changes that need to be made to the draft rule for the new Medicare physician payment system so it works for physicians and their patients.

The AMA is urging changes across the reformed program as well as revisions that are specific to the Merit-based Incentive Payment System (MIPS) and the alternative payment model (APM) option.

Three of the overarching program recommendations call on CMS to:

Changes needed to improve MIPS
The comments outline several key recommendations regarding MIPS, which currently is comprised of four components. The comments ask CMS to:

Changes needed to improve the advanced APMs option
MIPS is a revised fee-for-service model that most physicians will participate in initially. But the program allows for an alternative course through APMs that may work better for some practice types.

Physicians detailed several ways the APM option could be improved, including:

Physician organizations submit collective recommendations
More than 110 state medical associations and national medical specialty societies joined the AMA in a sign-on letter to CMS that called for simplification, an easier APM pathway, and accommodations for physicians in small and rural practices.

"The overall goal in MIPS should be to create a more unified reporting program with greater choice and fewer requirements," the letter said. "While we see several positive changes in the proposed rule, our main concern is that CMS continues to view the four components as separate programs, each with distinct measures, scoring methodologies and requirements."

Physicians identified in the letter several of the positive MIPS proposals that should be finalized, including reporting quality information through a variety of methods, such as electronic health records (EHR), clinical registry, qualified clinical data registry (QCDR) and group practice reporting.

Back to Top

State Update

3 things every physician should do when treating pain

A panel of physician experts offered three actions every physician can take to appropriately treat patients with acute or chronic pain. Presenting at the 2016 AMA Annual Meeting, they also discussed tools that can help keep patients safe from overdose and improve their quality of life.

The panel was comprised of physician representatives from the AMA Task Force to Reduce Prescription Opioid Abuse and one of the nation's leading health policy experts. In light of the opioid epidemic, the task force has put forth recommendations for physicians. Read more at AMA Wire®.

Back to Top

Judicial Update

Confidential patient safety information threatened in court case

An intermediate level appellate court in Florida last year held that patient safety information can be shielded from disclosure in a medical liability case. Now, that same case is on appeal—this time, in the Supreme Court of Florida.

What happened last year
In Southern Baptist Hospital of Florida, Inc. v. Charles, a trial court had ordered the release of medical documents used for patient safety and quality improvement efforts as part of litigation discovery. Then, in October of last year, a Florida district court of appeal overturned the trial court's decision and found that health care information, which was being used for patient safety improvement efforts, was privileged from discovery.

The district court of appeal held that the Patient Safety and Quality Improvement Act of 2005 (PSQIA) preempted a provision in the Florida constitution.

The PSQIA enables physicians and hospitals to share medical information used for quality improvement through a patient safety organization (PSO). The data within these systems is deemed privileged under the PSQIA, with the exception of requests that state administrative agencies might make for the information. If this information is not protected from litigation discovery, it could stifle the sharing of information and impede upon quality and patient safety improvements.

PSOs were established to gather and analyze information critical to the improvement of patient safety and quality of care. The information is submitted to PSOs in accordance with the PSQIA and is protected from disclosure as a patient safety work product (PSWP).

The appellate court's decision allowed for continued confidential sharing of patient safety information without fear of disclosure in medical liability litigation.

Protected patient safety information again under threat
Now on appeal in the Supreme Court of Florida, the case is focused on documents prepared as the result of a state legal requirement.

Both sides are in agreement on one thing: Physicians and hospitals must under some circumstances submit patient safety information upon request from a state agency—even with the protections afforded to PSWPs.

The twist in this particular case is that the PSWP information, although prepared as the result of a state agency requirement, was never submitted to the state agency because the agency did not request it.

The question before the Florida Supreme Court is whether, under the PSQIA, if the state agency does not request the PSWP documents from a physician or hospital, those documents will be protected from disclosure in medical liability litigation.

A reversal of the First District Court of Appeal holding would "effectively nullify the PSQIA in the state of Florida," the Litigation Center of the AMA and State Medical Societies said in an amicus brief.

"This court's reversal of the First District's ruling in this case," the brief said, "would undo the progress made to date and undermine the valuable work that has been done by PSOs and their member health care providers. Patients, who are the ultimate beneficiaries of the PSQIA, would suffer."

Back to Top

Other News

Physicians may be subject to sanctions for certain billing requirements

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—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. 

Please consider posting this notice in your organization's newsletters and/or online.  For further information, see MLN Matters, Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the QMB Program

How to talk to Congress about the issues

Members of Congress will be heading home in a few weeks for summer recess to meet with their constituents—now's the time to make sure you get a seat at the table to make sure your legislators are well-informed on the issues that you care about.

Learn more about how to conduct in-person visits with legislators and how to keep that relationship going at AMA Wire. Check out AMA resources to learn about Medicare payment reform, or visit to learn about advocacy efforts regarding student loan debt.

Back to Top