Physicians, lawmakers push for Medicare regulatory relief

The AMA and other doctor groups back a bill that, among other things, would reform the process for appealing denied claims.

By Jane Cys, amednews staff. March 12, 2001.

Washington -- The American Medical Association and specialty physician groups plan in early March to kick off a high-priority congressional effort focused on alleviating Medicare's regulatory burden on physicians.

The renewed push from doctors and other health care practitioners comes at a time when key congressional committees, lawmakers and Bush administration officials are beginning to take a close look at the Health Care Financing Administration and its management of Medicare.

Seeking relief

"It serves no one to have a Medicare system that is so burdensome that physicians who want to care for our nation's seniors are being driven away," said Thomas R. Reardon, MD, the AMA immediate past president.

"The AMA will work tirelessly this year to make changes in the system that allow physicians to get back to their primary focus, and that is treating patients."

The Medicare Education and Regulatory Fairness Act of 2001, which incorporates many of the regulatory reforms sought by the AMA and other physician groups, is expected to be introduced in the House and Senate early this month. Reps. Pat Toomey (R, Pa.) and Shelley Berkley (D, Nev.) are key House sponsors, and Sen. Frank Murkowski (R, Alaska) is a lead Senate sponsor.

Signs are promising that doctors' quest for regulatory relief may be rolled into lawmakers' ongoing efforts to examine whether HCFA needs to be overhauled so it can operate more efficiently for Medicare beneficiaries.

The House Energy and Commerce Committee, for example, has begun a series of hearings to review HCFA's major programs, policies and operations. Part of that review will focus on identifying and eliminating antiquated regulations, senior committee members said in a recent letter to Dept. of Health and Human Services Secretary Tommy Thompson.

"Governed by an estimated 130,000 pages of laws and regulations, many Medicare providers are spending as much time navigating their way through HCFA's complicated regulatory process as they are on patient care," the lawmakers said in the letter. "We are committed to changing this system so that health care professionals can better focus on improving patients' quality of care."

This House committee shares jurisdiction over Medicare and HCFA with the House Ways and Means Committee. Rep. Nancy Johnson (R, Conn.), chair of the Ways and Means health subcommittee, also plans to hold a series of hearings designed to lay the groundwork for reforming and modernizing Medicare. Regulatory reform is one of the issues that's expected to arise during those discussions.

In the Senate, the Finance Committee is expected to hold several hearings on Medicare, and the committee's chair, Sen. Charles Grassley (R, Iowa), has expressed an interest in looking at HCFA reform.

"Another concern of mine is the need to tailor legislative efforts to the reality of a rapidly changing health care environment," Grassley said at a recent hearing.

"Bureaucracy and innovation do not mix, and it would be folly for Congress to tie the hands of those seeking to bring more effective and efficient medical solutions which will improve the health and well-being of the Medicare population," he said.

During his confirmation hearings, Thompson acknowledged the Medicare regulatory burden. He noted, for example, that physicians and others are "fed up" with "excessive and complex" paperwork.

Sought-after reforms

Physician groups emphasized that their regulatory relief effort isn't related to fraud and abuse, and that the small number of doctors who do commit fraud should be punished. But the burden created by Medicare regulations, they said, can result in unintentional mistakes and frustration with confusing rules.

Dr. Reardon noted that the burden is one reason there's an increasing number of stories and statistics showing that physicians are refusing to accept new Medicare patients -- an action that he has considered taking himself.

One of the goals behind regulatory relief, he added, "is to stop this trend before it becomes a crisis."

The AMA-backed bill is more comprehensive than a similar one introduced late last year. It addresses several issues, including reforms to the Medicare audit process and to the appeals process that physicians use to challenge audit findings.

For example, the measure would allow physicians to return overpayments they mistakenly received within one year without the fear of being targeted for an investigation or audit, as long as an audit or investigation hasn't already been initiated.

The use of extrapolation -- a process by which carriers estimate the amount of an overpayment using a small sample of audited claims -- would be curtailed under the bill.

Carriers would also be prohibited from collecting alleged overpayments until physicians who have decided to dispute the audit findings complete the Medicare appeals process. This provision would not apply to fraudulent activity.

Robert Doherty, senior vice president of governmental affairs and public policy for the American College of Physicians--American Society of Internal Medicine, noted that the efforts to get relief from Congress may help lawmakers review their own role in adding to the regulatory burden.

"There's no question that Congress has added more and more requirements to HCFA, particularly from the Balanced Budget Act of 1997, which the agency is required to administer," he said. "But it really hasn't given the agency the resources it requires to keep up with all the mandates."

Toomey, one of the bill's sponsors, noted that HCFA has wide latitude to implement Medicare regulations. "I'm sure Congress deserves their share of the blame, but this [regulatory relief bill] is an effort to relieve some of the burden from HCFA-generated regulations," he said.

In addition to the push in Congress, physician groups also plan to urge HCFA to take a more active role in addressing regulatory relief issues at the administrative level. As an example, Doherty pointed out that local medical review policies could be made more clear to physicians.

The AMA, Dr. Reardon noted, recently sent a letter to the Bush administration asking it to further postpone several potentially burdensome Medicare and related regulations that President Clinton released before leaving office.

ADDITIONAL INFORMATION:

Seeking relief

The Medicare Education and Regulatory Fairness Act of 2001 incorporates many of the regulatory relief efforts sought by organized medicine. The AMA-backed bill would:

Ensure that physicians and others do not have to adhere to proposed Medicare rules until they officially become final. It also would prohibit carriers from retroactively applying new rules.
Bar carriers or fiscal intermediaries from collecting alleged Medicare overpayments from physicians or others while they are appealing audit findings.
Require carriers or fiscal intermediaries to allow Medicare overpayments to be recouped from physicians or others through a repayment plan or deductions from future reimbursements.
Enable physicians and others to legally challenge the constitutionality of Dept. of Health and Human Services regulations.
Reallocate funds from current budgets of carrier and fiscal intermediaries to education efforts for physicians and other practitioners.
Require the Health Care Financing Administration to postpone implementing new evaluation and management documentation guidelines until it completes at least four pilot programs. One pilot must reflect a peer-reviewed method and one must be conducted in a rural area.