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Medicare regulatory relief: Doctors see good in House, Senate reform bills

Physicians can expect better carrier relations and improved appeals and due process rights.

By Markian Hawryluk, amednews staff. July 21, 2003.

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Washington -- While congressional debate over Medicare payment provisions, managed care choices and prescription drug coverage continues to be rancorous, a group of often overlooked provisions in the Medicare reform bills is virtually assured of approval. The package could have profound impact on physician practices.

Both House- and Senate-passed versions of the Medicare reform legislation include extensive sections that would provide regulatory relief for physicians. Although each version contains physician-supported provisions that the other does not, physician groups are ecstatic that both chambers have passed meaningful reforms.

AMA Trustee J. Edward Hill, MD, said he expects that the conference committee of House and Senate negotiators will have little difficulty in reaching a final compromise on the paperwork reduction measures.

"We've got good things in both packages," Dr. Hill said. "What we're hoping will come out of the conference is a consolidation of the good things of both of these bills that give us some regulatory relief."

For example, physicians favor a Senate provision that would ensure a carrier medical director in every state. The Centers for Medicare & Medicaid Services had indicated it might consolidate the number of directors into fewer regional positions. That move would reduce physicians' ability to impact carrier decision-making, Dr. Hill said.

Physicians have been clamoring for years for limits on the use of extrapolation, a process by which carriers calculate an overall level of errors and overpayments from a small sample of physician claims. But only the House bill would limit extrapolation.

The House measure mirrors provisions of the AMA-supported Medicare Regulatory and Contracting Reform Act of 2001, which was passed by the House unanimously two years ago. Until this year, the Senate had run into difficulties even bringing its regulatory reform bill up for a vote, despite broad support for its provisions.

The extent to which physicians will see a marked difference in their dealings with Medicare remains to be seen, but physician groups are convinced the measures represent significant steps.

"I think over time they will see a noticeable change," said Pat Smith, senior vice president for government affairs at the Medical Group Management Assn. "A lot of the frustration from the people who manage the practices is in their dealings with the carriers. So the fact that providers can now get something back in writing, to get something in their hands, will prevent that feeling of inconsistency."

Both bills would require contractors to respond to physician inquiries with general written responses within 45 days. Physicians who reasonably rely on that guidance would be protected from sanctions and repayment requirements even if that guidance is in error.

Both bills also set aside funding for more physician Medicare education. The House bill would also require CMS to determine categories of items and services for which a physician or beneficiary could receive prior determination of coverage from the carrier. However, CMS officials have said in the past that such a proposal would be unworkable.

Nipping problems in the bud

Dr. Hill believes most physicians dealing with the program probably won't notice many of the changes that go into effect because they'll eliminate problems before they happen.

"If you do away with a time-consuming regulation, you don't really notice the pleasure of not having it anymore," he said. "If you continue to have it, you do understand the hassles on a regular basis."

For example, both House and Senate bills seek to prevent the issuance of evaluation and management documentation guidelines without physician input. Previous iterations of the documentation guidelines have been decried by physicians as needlessly complex. However, only the House bill would require pilot testing of any new guidelines.

While both bills would require the Bush administration to continue to look for ways to reduce paperwork hassles, the Senate bill sets a goal to cut the number of words in Medicare regulations by two-thirds by Oct. 1, 2004. If CMS was unable to meet that goal, it would be required to present a plan for a feasible reduction by 2005.

The House bill also contains reforms to the Emergency Medical Treatment and Active Labor Act that the Senate bill does not, including the creation of an EMTALA advisory board. CMS has indicated it will release new EMTALA regulations this summer, but it is unclear whether those regulations will address concerns included in the legislation.

Emergency physicians are perhaps most vulnerable to the burdens of Medicare because, unlike other specialties, they cannot opt out of the program due to EMTALA regulations, said John Turner, an emergency physician from Knoxville, Tenn. Making EMTALA and Medicare less burdensome would help retain a supply of emergency physicians, he said.

"We will continue to, and are happy to, see all patients in the emergency department regardless of their payer status or ability to pay, but it is becoming more and more difficult to provide universal emergency care to all patients who need it," Dr. Turner said.

New rights for doctors

The legislation contains many provisions that the average physician will notice "especially when things go wrong," said Jean Harris, associate director of advocacy and health policy at the American College of Surgeons. The bills would offer a host of new due process and appeals rights. Doctors would be able to correct minor errors in claims and submit additional information without having to go through the appeals process.

Contractors would be barred from recouping overpayments until independent contractors had reviewed the cases. And a physician whose enrollment application or renewal was denied could appeal that decision. In cases in which immediate repayment would constitute a hardship for practices, the measures would allow CMS to enter into longer-term repayment plans.

At press time, work on fusing the two bills was expected to continue into late July or August. Once a compromise is reached, both the House and Senate would have to approve the final bill before sending it to President Bush to sign into law. Many of the regulatory relief provisions would take effect on the date of enactment.

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