Sandy Coffta.
We pay a lot of attention to government regulation in healthcare, especially the Medicare Physician Fee Schedule (MPFS), which influences reimbursement not only from Medicare but also from other payers as many commercial contracts are tied to the MPFS. Although it is the object of most focus, the U.S. Centers for Medicare and Medicaid Services (CMS) is not the only agency that regulates healthcare.
MPFS
As of this writing, Medicare reimbursement for 2024 is nominally 3.4% lower across the board than it was in 2023 due to the statutory calculation that goes into the fee schedule conversion factor. Several pieces of legislation are pending in Congress that would modify the pricing methodology:
- HR 6683, the Preserving Seniors’ Access to Physicians Act of 2023, was introduced December 7, 2023, to make a one-time adjustment to the MPFS for 2024 by returning the conversion factor to the 2023 level. Although there are 56 cosponsors, it is sitting with the House Subcommittee on Health as of December 8 with no further action.
- H.R. 6545, the Physician Fee Schedule Update and Improvements Act, was introduced December 1, 2023, and it is with the Committee on Energy and Commerce as of December 6. It would make several short-term fixes to the fee schedule, but importantly it would begin to tie the conversion factor adjustment to the Medicare Economic Index, which is a more relevant measure of practice costs.
- H.R. 2474, the Strengthening Medicare for Patients and Providers Act, was introduced April 3, 2023. It would make a permanent change to the conversion factor calculation by tying it to the Medicare Economic Index. Although there are 82 cosponsors, it has remained in the Subcommittee on Health since April 14, 2023.
The conversion factor is just the beginning of the story because there are quite a few factors that go into determining the final rate that your practice is paid for Medicare services. The valuation of some procedures is revised periodically under the Relative Value Unit (RVU) system based on an assessment of the level of work and the cost of providing the procedure. In some geographic areas, changes to the Geographic Practice Cost Index (GPCI) are significant. We will analyze the impact of those various changes in an upcoming article.
Appropriate Use Criteria (AUC)
The MPFS Final Rule for 2024 included a suspension of the regulation that would have penalized radiologists for the failure to order physicians to consult AUC when ordering advanced diagnostic imaging. All Medicare contractors were recently instructed to remove national and local edits related to the AUC program as of January 1, 2025, according to a report by attorney Tom Greeson of ReedSmith.
The No Surprises Act (NSA)
Since it became effective on January 1, 2022, there have been numerous legal challenges to the portion of the NSA dealing with the Independent Dispute Resolution (IDR) process. The challenges have come from the physician community because the IDR process defined within the NSA to determine a price for services was unfairly skewed to the benefit of the insurance company payers.
There are also concerns about the administrative fees related to filing a dispute, and the way the system of batching claims is set out. Although some changes have been made to the NSA regulations, the provider community is continuing to push for a fairer system.
For radiology practices, use of the IDR process has been minimal. Radiology practices typically participate with most payers, especially those with which their hospital participates, thus avoiding situations where a dispute over a non-covered service would arise. Fees for individual radiology procedures also tend to be relatively low, which means that the cost of filing a dispute would generally outweigh the benefit of increased reimbursement. Improvement of the ability to batch claims would possibly provide an avenue for the filing of disputes in certain circumstances.
Breast density notification
Mammography providers have until September 10, 2024, to comply with the U.S. Food and Drug Administration (FDA) requirement that they must notify their patients about the density of their breasts. The requirement was first announced in March 2023 for facilities that are subject to the Mammography Quality Standards Act (MQSA). A recent bulletin says, “It is important to note that FDA may take enforcement action for noncompliance with the MQSA regulations, whether observed during an annual inspection or determined by other means.”
The bulletin also gives the new items that MQSA inspectors will be looking for, including:
- Mammography reporting criteria with assessment of findings classified into specific categories
- Patient lay summaries that include the specified statements listed in the bulletin
- Criteria for communication of results when the assessment is "suspicious" or "highly suggestive of malignancy"
- A medical outcomes audit
Most states already have breast density notification regulations in effect, only 12 do not. The federal regulations may be more or less stringent than some states but it likely will serve to standardize reporting nationwide.
Information Blocking Rules
Compliance with the CMS Information Blocking requirements went into effect on April 5, 2021. As we reported, “The intent of the law is to promote the free flow of relevant healthcare information between providers and to ensure that patients can access their own information where and when they need it. A better name might have been the “information sharing” or “anti-information blocking” law!”
There have not been any penalties for failure to comply with the law, but a proposed rule issued on November 1, 2023, includes disincentives for providers found to be in violation.
According to the American College of Radiology, “the program has significantly evolved since [April 5, 2021], with major regulatory changes and publication of assorted HHS guidance, including on compliance issues raised by the American College of Radiology.” The ACR reports that the provider disincentives that would be used in place of financial penalties include the following:
- Information about violations would be published online.
- Eligible hospitals or critical access hospitals would not be considered meaningful users of an electronic health record (EHR) system for the year.
- Participants in the Merit-based Incentive Payment System Quality Payment Program would not be considered a meaningful user of certified EHR technology during the performance period.
- Accountable care organizations (ACO), ACO participants, or ACO providers/suppliers would not be eligible to participate as, or in, an ACO for at least one year.
Following a 60-day comment period on the proposed rule, a final rule will be issued with an effective date for implementation.
Sandy Coffta is vice president of client services at Healthcare Administrative Partners.
The comments and observations expressed are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.
