Medicare & Medicaid

Pay schedule contains AMA advocacy wins on telehealth, diabetes

Andis Robeznieks , Senior News Writer

AMA News Wire

Pay schedule contains AMA advocacy wins on telehealth, diabetes

Sep 29, 2023

The AMA is fighting to stop the unacceptable 3.36% pay cut contained in the proposed 2024 Medicare physician payment schedule, calling it “unsustainable and unconscionable.”

However, there is evidence elsewhere in the 2,000-page document that the Centers for Medicare & Medicaid Services’ (CMS) has been listening to and acting on some of physicians’ other policy priorities.

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The AMA has achieved recent wins in 5 critical areas for physicians.

Specifically, CMS appears to be following AMA recommendations to continue or implement policies on telehealth and diabetes prevention, while delaying implementation of problematic proposals regarding its Appropriate Use Criteria (AUC) program for advanced diagnostic imaging and for billing of split or shared evaluation-and-management (E/M) visits.

Regarding telehealth, CMS has proposed maintaining the waiver of geographic and originating site restrictions through Dec. 31, 2024. The waiver began during the COVID-19 public health emergency (PHE) and has allowed Medicare beneficiaries to connect with their physicians anywhere in the U.S. from the comfort of their homes.

The importance of these flexibilities in enhancing patient access to care has been made “abundantly clear,” AMA Executive Vice President and CEO James L. Madara, MD, said in a letter to CMS.

“The COVID-19 PHE clearly demonstrated the value of telehealth services and, more broadly, of digitally enabled medical care combining in-person, virtual, remote monitoring, and other service modalities to deliver care that meets patient needs,” Dr. Madara’s letter (PDF) says.

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Another year of Medicare physician pay cuts is unconscionable

In addition, CMS has proposed extending payment for audio-only telephone visits as well.

Dr. Madara urged CMS to join efforts in supporting the CONNECT for Health Act of 2023, a bipartisan proposal now pending in Congress that would permanently extend the pandemic related telehealth policies in the Medicare program.

Regarding remote-patient monitoring, the AMA recommended that CMS modify its proposed policy clarifications to avoid imposing new restrictions on these services that do not exist in the Current Procedural Terminology (CPT®) code set.  For example, patient eligibility for remote monitoring services should not depend on whether they are new or established patients.

The AMA applauded the CMS proposal for including coverage of the hemoglobin A1C (HbA1c) testing for diabetes and prediabetes screening, calling it a “significant step forward,” and commended CMS for being responsive to concerns raised by the AMA and the Diabetes Advocacy Alliance.

“By adopting this coverage, CMS ensures Medicare’s alignment with contemporary clinical standards, fostering more frequent screenings and early interventions for diabetes among Medicare beneficiaries,” Dr. Madara’s letter says. “We encourage the agency to waive patient deductibles for HbA1c tests to encourage their utilization and eliminate cost barriers, especially for historically marginalized communities.”

The proposal also includes removing the limit on one prediabetes screening test per year.

The AMA supports the CMS proposal to pause implementation of the AUC program and to rescind current program regulations until necessary modifications can be made. This includes requiring consultation of AUC for advanced diagnostic imaging services by an ordering professional and claims-based reporting of the AUC information by the rendering professional.

“The concerns surrounding the burden, technical challenges, and workflow disruptions associated with the AUC Program are well-founded, and we believe that physicians need flexibility in consulting physician-developed, evidence-based, and transparent AUC or advanced diagnostic imaging guidelines,” Dr. Madara’s wrote.

“We are glad that CMS heard the AMA’s concerns about the burden of these requirements and their potential negative impact on beneficiary access to care,” the letter adds. “CMS also cited concerns that claims would be inappropriately denied, data integrity and accuracy would be lacking, and beneficiaries would potentially be financially liable for advanced diagnostic imaging services.”

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Inside the proposed 2024 Medicare physician pay schedule

CMS is delaying for one year implementation of its plan to only allow the physician or nonphysician health professional who spends more than half of the total time with a patient during a shared E/M visit to bill for that encounter.

In its rationale for a delay, CMS cited concerns (PDF) raised by the AMA and organized medicine about the disruptions to team-based care that would result from this policy.

The AMA supports the one-year delay in implementing this policy and recommends that, effective Jan. 1, 2025, CMS adopt CPT guidelines that allow reporting of E/M services in a split or shared visit to be based either on time or the level of medical decision-making.

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While working on these issues, the AMA continues efforts to reduce the 3.36% cut to the conversion factor in the CMS proposal.

In addition to lowering physician payment by 3.36%, CMS estimates that the cost to practice medicine—as measured by the government’s Medicare Economic Index (MEI)—will go up 4.5% in 2024. 

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“This imbalance poses a serious threat to the stability and vitality of medical practices across the nation and contributes to high rates of burnout among physicians,” Dr. Madara’s letter says.

Leading the charge to reform Medicare pay is the first pillar of the AMA Recovery Plan for America’s Physicians.

The AMA has challenged Congress to work on systemic reforms and make Medicare work better for you and your patients.

The AMA is strongly urging (PDF) Congress to make significant refinements to the Medicare physician payment law passed in 2015 that would support physicians provision of high-quality patient care while removing some of the most administratively burdensome aspects of the current system.  

The AMA and its partners in organized medicine strongly support (PDF) H.R. 2474, the Strengthening Medicare for Patients and Providers Act. That measure would provide a permanent, annual update equal to the increase in the MEI and allow physicians to invest in their practices and implement new strategies to provide high-value care.

Learn about how you can take part in the fight to fix Medicare on behalf of your patients and practices at the AMA's Fix Medicare Now website.