Advocacy Update

Aug. 23, 2019: National Advocacy Update


The AMA recently submitted comments in response to the Centers for Medicare & Medicaid Services' (CMS) Request for Information on "Reducing Administrative Burden to Put Patients Over Paperwork."

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The AMA continues to support this initiative and the agency's goal of alleviating the administrative burden federal programs place on physician practices. The increasing amount of administrative responsibility forced upon physicians adds unnecessary costs to practices and the Medicare program—and also negatively impacts patient care. The AMA argued that by reducing administrative burden, CMS can support the patient-physician relationship and let physicians focus on an individual patient's welfare and, more broadly, on protecting public health.

The AMA made recommendations on a variety of topics including addressing prior authorization, simplifying the Quality Payment Program (QPP), eliminating observation status, reforming open payments, streamlining appropriate use criteria and many more. Specifically, with prior authorization, the AMA urged CMS to take a leadership role and develop a comprehensive strategy to address concerns that includes all areas of the AMA Prior Authorization Consensus Statement (PDF):

  • Selective application of prior authorization (CMS should continue the successful Targeted Probe and Educate program; the AMA supports identification of outliers and education as needed.)
  • Review/adjustment of services/drugs that require prior authorization to eliminate low-value prior authorization (Applying prior authorization to services with high approval rates is costly for plans and providers.)
  • Improved communication of prior authorization requirements to patients and health care professionals (including CMS encouraging plans to disclose the clinical basis for their prior authorization requirements)
  • Protections of patient continuity of care, particularly when patients enroll in new plans or plans change prior authorization requirements
  • Automation to improve prior authorization transparency and process efficiency while maintaining physician oversight of payer access to electronic health record (EHR) data

Several physician organizations signed a letter to the U.S. Food and Drug Administration (FDA) urging the administration to retain language in a proposed draft guidance document that would preserve the ability of physicians to prepare sterile drug products in their offices for direct administration to patients. The draft guidance, "Insanitary Conditions in Compounding Facilities," was revised following serious concern from the physician community that it would jeopardize the ability of physicians to provide certain treatments to their patients. In response, the FDA released the revised guidance with language noting that it planned to exercise enforcement discretion with regards to physician offices, so long as physicians were preparing drug products only for direct administration to their own patients in an office setting.

While the physician community was pleased with the revised draft guidance, recent interactions with agency officials raised some concern that they may be looking to add more restrictions on physician offices. The letter in response to those interactions reiterates the necessity of maintaining access to these critical treatments and urges the FDA to engage with the physician community before finalizing any guidance that will impact the treatments available to patients.

The U.S. Department of Veterans Affairs (VA) launched a new community care program for veterans under the MISSION Act. A replacement for the Veterans Choice Program and other existing programs, the new community care program signifies a long-term commitment to partnering with community-based providers to deliver care to eligible veterans when the VA cannot do so in a timely manner, patient travel times exceed a certain threshold and other scenarios.

Now, the VA's existing community care legal authorities for veterans are rolled into one program. There is one contracting process, one set of rules, one set of eligibility criteria and a new claims processing system to reduce payments delays that plagued the Veterans Choice Program. The VA has a number of educational tools and webinars that will help get community-based providers up to speed on what the new program means for their practice.

HealthShare Referral Manager (HSRM) is a secure, web-based system VA uses to generate and transfer referrals and authorizations to community providers. By using a standardized process, HSRM enables community providers and VA to better manage and understand referrals and authorizations, thereby reducing denials and payment delays.

VA hosts an HSRM webinar for community providers every Tuesday from 1 – 3 p.m. Eastern time. Please note that a VHA TRAIN account is needed to register.

VA Office of Community Care overview webinar

The VA hosts monthly webinars summarizing the community care program and the corresponding VA regulations. These webinars include in-depth discussion on topics from referrals and authorizations to claims processing to community care modernization and improvements.

These webinars are held on the third Thursday of each month from 1 – 3 p.m. Eastern time. Please note that a VHA TRAIN account is needed to register. Please follow the link to register.

Starting Jan. 1, 2020, practices seeing Medicare beneficiaries must use the patient's Medicare Beneficiary Identifier (MBI) to submit claims. CMS will reject claims using the patient's Health Insurance Claim Number (HICN), with a few exceptions, and will reject all eligibility transactions using the HICN.

There are multiple ways to obtain a Medicare beneficiary's MBI:

  • Ask your patient for their card. If they did not get a new card, give them the "Get Your New Medicare Card" flyer in English or Spanish.
  • Use your Medicare Administrative Contractor's look-up tool. Sign up for the portal to use the tool.
  • Check the remittance advice. CMS returns the MBI on the remittance advice for every claim with a valid and active HICN.

For more information, see the AMA's MBI web page and CMS' MLN Matters Article (PDF).

AMA President Patrice A. Harris, MD, MA, recently wrote about how our nation can provide the highest-quality and more affordable health care for patients. An excerpt follows:

Health care remains a major theme in our national conversation. And as we approach the November 2020 election, we will hear a lot of debate about the right path forward to fix what ails our current system. It is encouraging to hear so many people—candidates, policymakers, opinion leaders and others—asking how our nation can provide the highest-quality and most affordable health care for patients.

The AMA strongly believes that every American should have access to meaningful, affordable coverage. We also believe we need to build on our current system of coverage provided by employers, government, and individually selected plans so that patients can benefit from choice and competition. This fits with our long-standing policies of pluralism, freedom of both choice and practice and universal access for patients.

Preserving the ability of patients to choose the health plan that best fits their needs must be a priority. Also, retaining variety in the potential payer mix for providers while reforming payment and delivery processes is an essential element in fully covering the costs of care and ensuring practice sustainability.

Improving upon the Affordable Care Act (ACA) does not upend the model of employer-based health coverage, which has been the predominant form of U.S. medical insurance for the nonelderly population for many decades. In short, health insurance should cost less and work better for those who already have it, and should be much easier to obtain for those who don't.

Read the full story here.

The Wall Street Journal recently sat down with AMA President Dr. Patrice Harris to discuss fighting government intrusion into the patient-physician relationship, improving public health, advocating for affordable and meaningful health insurance coverage, and promoting diversity. An excerpt follows:

Under a new President, Patrice Harris, MD the AMA made a splash in the reproductive-rights debate in June by suing North Dakota to block two abortion-related laws. One of those laws requires physicians to tell patients that medication-induced abortions can be reduced in some instances, which the suit says is false; the other requires doctors to tell patients that an abortion terminates "the life of a whole, separate, unique living human being."

The AMA also has recently taken positions on some topics, such as climate change and body-worn cameras in law enforcement, that aren't traditionally associated with medicine.

Dr. Harris, who will serve a one-year term as president, spoke to the Wall Street Journal about the AMA's advocacy efforts, health-care reform and diversity in the profession.

Read the full story here.