July 14, 2023: National Advocacy Update

The AMA recently urged (PDF) the Centers for Medicare & Medicaid Services (CMS) not to increase prior authorization (PA) requirements in Medicare Fee-for-Service (FFS). While the AMA supports technology solutions that would modernize access to Medicare FFS PA and claims requirements, the AMA strongly objects to PA policy changes that would negatively impact both Medicare beneficiaries and physicians.

Year after year, evidence shows that patients are being harmed by PA requirements, and medical practices are overburdened by being forced to jump through administrative hoops. In a 2022 AMA survey (PDF), 94% of physicians reported that PA causes care delays, 80% indicated that the process can lead to treatment abandonment, and an alarming 33% said that PA had led to a serious adverse event for a patient in their care. The AMA pointed out that just because there are technological improvements to conduct PA, does not mean there should be more PA. The AMA also stressed that any plan to increase PA in Medicare FFS would be out of alignment with CMS’ own goals to reform. The AMA continues to aggressively advocate for significant reductions of PA and a reevaluation of the effectiveness of PA across all health plans and insurers. 

The National Committee on Vital and Health Statistics (NCVHS)—a federal advisory body to the Secretary of Health and Human Services (HHS)—recently issued recommendations regarding adoption of updated electronic transaction standards (PDF) and new and updated operating rules (PDF). NCVHS’ recommendations to the HHS Secretary completely aligned with the AMA’s written comments (PDF) and hearing testimonies, representing a major advocacy win in reducing administrative burdens and costs for physician practices.  

NCVHS recommended:  

• Against adoption of new versions of the X12 electronic claim and remittance advice transactions, citing arguments made by the AMA and other stakeholders on the lack of information on the expected costs and ultimate value of this transition. 
• That HHS address concerns raised by the AMA and others regarding virtual credit card payments and inclusion of the unique device identifier on electronic claims. 
• Adoption of operating rules that will improve the quality and quantity of data in electronic eligibility responses, increase security of electronic transactions and better support physicians’ successful participation in value-based contracts. 

As detailed in a joint AMA and American Hospital Association letter (PDF), these operating rules offer considerable benefit to health care professionals and address unmet business needs and emerging market trends. The AMA’s successful advocacy with NCVHS will result in reduced administrative burdens, while also protecting practices from mandates to adopt costly, unproven new technology. 

Last week, the Departments of Health and Human Services, Labor and Treasury (the Departments) released a new set of FAQs (PDF) on the No Suprises Act (NSA). The FAQs clarify that under the Transparency in Coverage provisions of the law, health plans are required to make price comparison information for covered facility fees available to patients through an internet-based self-service tool and in paper form, upon request. Additionally, physicians and facilities are required to provide good faith estimates to self-pay or uninsured patients in connection with facility fees. Finally, the Departments state that future rulemaking on the Advanced Explanation of Benefits (AEOB) provisions of the law will include any facility fees charged by a facility or physician/other provider as part of the price information required to be provided to patients.  

The FAQs also clarify that cost-sharing for services provided by out-of-network physicians and other health care providers for purposes of the NSA is considered out-of-network in terms of the maximum out-of-pocket (MOOP) limit for patients.   

Also released last week, a first report (PDF) to the Congress from the Department of Health and Human Services on the impact of the NSA on the health care market. Suggesting that it is still early to provide a market impact analysis, the report generally (1) provides a landscape analysis of state surprise billing laws and consolidation and competition among health plans, physicians and hospitals and (2) creates a framework for future reports to Congress on the NSA impact.   

On July 7, the AMA submitted comments (PDF)  in response to the White House Office for Science and Technology’s (OSTP) request for information (RFI) on national priorities for artificial intelligence (AI). The RFI sought information on a number of questions, including on: 

• Specific measures that should be taken to protect individuals’ rights and safety while using AI 
• What type of oversight is necessary 
• What opportunities and risks to equity AI presents 
• How to ensure individuals are equipped to interact with AI 

AMA comments highlighted current AMA policy on augmented intelligence and brought attention to new policy on AI oversight from the June 2023 House of Delegates meeting. The AMA focused on the need for transparency mandates for the entire spectrum of health care AI, including that used by health insurers in making claims determinations. Comments also urged the administration to ensure appropriate standards are in place to govern the design and development of AI and also highlighted the risk for AI to exacerbate equity issues through bias. The AMA also raised concerns regarding the protection of patient data and physician liability.  

The AMA will continue to work closely with the administration to ensure that the design, development and deployment of AI is done in a responsible, ethical, transparent and equitable manner. 

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) published a final regulation around enforcement of the 21st Century Cures Act information blocking provisions and civil monetary penalties up to $1 million per violation. This enforcement regulation focuses on the following entities: health IT developers of certified health IT (EHR vendors) and health information exchanges (HIEs)/health information networks (HINs). Enforcement starts on Sept. 1. 

The OIG’s enforcement priorities will focus on information blocking that: 

• Has resulted in, is causing or had the potential to cause patient harm
• Has significantly impacted a provider’s ability to care for patients
• Was of long duration
• Has caused financial loss to Federal health care programs, or other government or private entities
• Was performed with actual knowledge

In instances where physicians believe an EHR vendor is blocking information unnecessarily or using legal or financial roadblocks to prevent access to patients’ medical records, that EHR vendor may be an information blocker and subject to enforcement. To report complaints about information blocking, please visit the ONC Information Blocking Portal or the OIG Hotline. 

HHS is working on a separate regulatory process for provider information blocking and disincentives with an expected proposed rule out this fall. 

The AMA recently weighed in on two proposed rules from CMS that would aim to strengthen payment adequacy and expand coverage for Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries. Specifically, the “access rule” includes new price transparency and other provisions intended to expand access for all Medicaid beneficiaries and the “managed care rule” includes updates to requirements for the Medicaid Managed Care and Children’s Health Insurance Program plans intended to enhance transparency, align them with Medicaid fee-for-service requirements, and improve their financing and quality overall.  

In general, the AMA expressed strong support for the proposed changes, reiterating its commitment to advocating for expanding and strengthening health insurance for all. In both letters, the AMA thanked the agency for being responsive to previous AMA feedback to strengthen coverage for patients, particularly regarding network adequacy, while acknowledging the current challenges state Medicaid agencies face with the unwinding of continuous enrollment requirements. In the letter (PDF) responding to the “access rule,” the AMA specifically urged CMS to finalize provisions to improve pricing transparency, disaggregate quality data to promote equitable access, and strengthen public feedback in future Medicaid policy development.  

In comments (PDF) on the “managed care rule,” the AMA urged CMS to finalize new federal wait time standards, robust minimum loss ratio requirements, increased pricing and quality data transparency, and enhanced oversight of network adequacy and overall access. In both letters, the AMA also reiterated previous calls to increase overall Medicaid rates to a minimum of parity with Medicare rates in order to preserve Medicaid beneficiary access to care. 

A brief on modifier 25 (PDF) is headlining the new “Practice Management” section on the AMA issue brief webpage. The brief was developed based on a Council on Medical Service report (PDF) that was adopted during the June 2023 Annual Meeting.

The Council on Medical Service report recommends that the AMA support mechanisms to report modifiers appropriately with the least administrative burden possible, including the development of electronic health record tools to facilitate the reporting of multiple, medically necessary services supported by modifier 25 and comprehensive education for physicians and insurers on the appropriate use of modifier 25. 

The modifier 25 brief may set the stage for future practice management briefs. 

For AMA members and their spouses, medical students and residents, and state medical association staff who want to become more involved in the campaigning process, the 2023 AMPAC Campaign School will be taking place in-person, Oct. 12-15, at the AMA offices in Washington, D.C.   

Running an effective campaign can be the difference between winning and losing a race. That is why the campaign school is designed to give participants the skills and strategic approach needed out on the campaign trail. AMPAC’s team of political experts will teach participants everything they need to know to run a successful campaign.   

During the two and a half day in-person portion of the program, under the direction of political experts, participants will be broken into campaign staff teams to run a simulated congressional campaign using what they have learned during group sessions on strategy, vote targeting, social media, advertising and more.     

• July 14, 2023: Medicare Payment Reform Advocacy Update