Practicing Physicians Advisory Council (PPAC) UpdateDate: November 19, 2003 The Practicing Physicians Advisory Council is a council of 15 physicians from across the county charged with advising Medicare (CMS) on the effects of regulatory changes on physician practice. We met on November 17, 2003 and I would like to report our discussions to you. RECOMMENDATIONS FROM THE SEPTEMBER 2003 MEETING Limited English Proficiency CMS did not adopt our recommendation from the September meeting that CMS work toward changing the statute to remove physicians from the mechanism for payment and from responsibility for the evaluation of interpreters and translators. We had requested that the interpreters bill Medicare, Medicaid or the private insurance company directly rather than having the physician pay. We had pointed out that physicians who need an interpreter are not in a position to understand the abilities of the interpreter. However, HHS felt that it was inappropriate to remove the physicians from the evaluation of the adequacy of the interpreter. CMS will continue to work with Office of Civil Rights to try to decrease the financial burdens. Doctors Office Quality Update PPAC recommended in September that the outcome of the Doctors Office Quality Project be used for quality improvement purposes and not for public information and dissemination. CMS adopted this request with modification. They felt it was currently premature to publically disclose quality measures of individual physicians. We had also requested that the Quality Measurement and Health Assessment Group assess the cost to participants and to CMS of the Doctors Office Quality Project and report those data to PPAC when available. This was adopted with some modifications as to what could be reported. Provider Enrollment PPAC had requested in September that CMS retain the current practice of allowing four consecutive calendar quarters to pass before a supplier's billing number became inactive, instead of CMS' new proposed rule to change this to only one quarter (3 months). We further that CMS not institute a requirement for all physicians to reapply for Medicare every three years. CMS justification is to reduce fraudulent billing using stolen billing numbers from deceased or inactive physicians. We requested that CMS compare the threat posed by physicians to the threat posed by DME providers to the Medicare Trust Fund, and to compare the physician threat with the cost to private physicians of more frequent re-validation. We learned at the September meeting that only a small percentage of the fraudulent billing problems are from physicians as opposed to DME suppliers, but CMS felt that they did not have the ability to do a cost study and did not adopt this recommendation. They did adopt our recommendation that CMS continue to pursue simplified alternatives to the proposed rule and seek less expensive and less onerous ways to get the data CMS requires. We also recommended that CMS aggressively pursue a web based enrollment system that provides immediate feedback on the completion of the form with a 21 day time limit for CMS response. The reply to our recommendations that CMS refrain from imposing a 3 year re-validation requirement and continue working with the physician community to resolve differences concerning the burdens and requirements of this proposed rule is pending, and has been passed to the rule writers who will be printing the final rule in early 2004. Payment Reform for Part B Drugs PPAC made several recommendations last time about Part B drugs, including that Medicare should pay the full physician cost with adequate margins to ensure access for Medicare beneficiaries. CMS felt that any reform should ensure access but does not feel that their current proposals will hinder it. They also adopted our request that the selected proposals should include adequate increases in payment to physicians to administer drugs and that the saving from drug payments be applied to physician administration costs and not trigger cuts elsewhere. Our suggestion that the selected proposal be applied to all specialties, drug classes and remedies is referred to the rule writers for comment. CMS stated that they agree in principal. CMS did adopt our recommendation that it would continue to explore alternative data sources for practice expense in any revision of drug administration payments. They adopted with modification that changes in reimbursement for "incident to" drugs should reflect changes in the mechanism that Congress developed and that they will delay implementation of any proposed rule until Congress has had time to act or until MEDPAC or another appropriate entity has had time to evaluate the shift of cost from Part B to Part A. PPAC also recommended that the competitive acquisition model not be accepted because the vendor distribution organizations have not demonstrated any savings to CMS or improvements in patient care. This response is still being considered. EMTALA Many of our recommendations from June 2002 on EMTALA are going to be adopted into the final rule. In particular we had discussed that physicians not be required to restrict their activity while on call to cover their on-call responsibility and that EMTALA does not apply to patients coming to the Emergency Department to obtain previously scheduled or follow-up care. There had been statements on Medicare Plus Choice plans which we had requested be dropped because they were related to reimbursement, not treatment, and CMS did drop those. However, we had also recommended that the Secretary's Advisory Committee create an Emergency Services Cooperative Project to address such issues as reimbursement mechanisms for EMTALA related services when patients don't have insurance. This was not adopted because CMS has no authority in the statute to pay for services for anyone other than Medicare patients. We had also requested that the Secretary's Advisory Committee modify the enforcement procedures for EMTALA by mandating early review by PRO (now QIO), but this was not adopted. CMS will adopt our recommendation that EMTALA regulations be revised at some time in the future to include the concept that compliance with pre-established community protocols for triage treatment and distribution of patients during a declared multicasualty incident as defined by community needs does not violate EMTALA. NEW BUSINESS ESRD The Office of Clinical Standards and Quality did a presentation on the End-Stage Renal Disease Quality Initiative. This initiative consists of public reporting of standards for dialysis units, end-stage renal disease vascular access improvement, a QIO project for chronic kidney disease with cardiovascular disease (a pilot project occurring in Georgia), and finally a disease management demonstration. We also briefly touched on the fact that in the physician fee schedule the current codes for dialysis have been replaced by a series of G codes which correlate with the number of nephrologist visits per month. PPAC discussed the fact that the number of nephrologist visits is being used as a surrogate for quality of care without any data. PPAC made a recommendation that CMS do a demonstration project for physician incentives with a cost offset from hospital savings. CMS promised to involve the pertinent nephrology physician organizations in this demonstration project if it agrees to accept this recommendation. Under the Vascular Access Improvement Initiative, it was pointed out that CMS pays less for an AV fistula as compared with a graft and that may be associated with diminished quality of care. PPAC requested that surgeons who perform vascular access surgery have an increase in reimbursement for AV fistulas to the same reimbursement provided for grafts. We also requested that CMS create a code for pre-op venous mapping. Physician Fee Update The major topic of conversation at PPAC was of course the physician fee schedule update. The update for 2004 through CMS's formula is minus 4.5%. Mr. Scully addressed the group and correctly predicted that the prescription drug bill would pass which changes it to a 1.5% increase for two years. The formula used to calculate the fee update has been modified to do a better job of looking at the changes in professional liability insurance. However, this is of minimal benefit to physicians because the increase in the PLI pricing component of the sustainable growth rate formula must be made budget neutral. Therefore another decrease was made in the work unit RVU as well as the practice expense RVU. This methodology was selected by CMS rather than using the conversion factor because they didn't want a conversion factor to be even lower than the minus 4.5%. This will minimally help physicians in professional liability crisis states and minimally harm physicians in professional liability non-crisis states. OIG We heard discussion from the Office of the Inspector General's chief counsel on the proposed OIG work plan for the next several years. It was pointed out that out of over 836,000 investigations, only 37 physicians had been convicted and those were blatant fraud. However, the OIG work plan includes studies of medical necessity, studies on the accuracy of coding, studies on appropriate costs, and fraud and abuse. In the coding arena, they are going to be watching for up-coding and will be evaluating E&M codes, use of modifier 25, the radiation therapy codes, and Place of Service errors. However, when questioned by PPAC about which E&M system they proposed using, they did not know but presumed it would be the one that was in effect at the time when the charge was submitted. Their concerns on fraud and abuse were excluded services, long distance claims, and patients who had expired. PPAC did point out that some patients will die before the bill can be submitted and that billing on a patient who has died is not necessarily fraud. OIG has an advisory opinion process where physicians can get advice on anti-kickback laws and has a Program Compliance Guide set up for small practices. When the OIG does find that the provider relied on inaccurate advice from the Medicare carrier, they do not prosecute the provider and do inform CMS and the contractor of the error. OIG and Electric Wheelchairs An interesting discussion was held on electric wheelchairs. In particular Harris County of Houston, Texas in 2001, 10 million dollars were spent on wheelchairs and in 2002, 168 million dollars were spent on electric wheelchairs. The bill for 2003 is expected to be 1.2 billion dollars. There is a significant amount of fraud occurring but there is also a significant amount of advertising direct to consumers that all they have to do is get a physician's signature and they, too, can have an electric wheelchair. PPAC discussed how this might be controlled. PPAC recommended that CMS develop a brochure and guidelines on power wheelchairs which physicians can use to give to their patients. It was pointed out by PPAC that the increase in the wheelchair bill will contribute to hitting the SGR target resulting in even lower fees. We agreed that the physician community would be motivated to decrease the use of electric wheelchairs unless there is clear medically necessity. It was also recommended that physicians get an annual report on the DME orders under their UPIN number so that they might aid in catching DME companies who are using the UPIN without authorization. Medicare Beneficiary Appeals Process We heard further testimony on how beneficiaries can appeal if they either have been denied a treatment which has been ordered or they have had the treatment and payment was denied. This can now be used to change a coverage decision instead of simply being applicable to the one case in question. Professional Courtesy and Waiving Co-Pays Professional courtesy was discussed by the Chief of the Industry Guidance Branch for the OIG. PPAC was told that the OIG is not very concerned about waiving fees for other physicians unless this is done in order to generate referrals. Also if, in good faith, patients are financially assessed individually to determine if they are not able to afford their co-pay, Medicare will not use that as a mechanism to lower usual and customary fees for determining Medicare allowable charges. Physician Communications The General Accounting Office did a survey of information given to physicians from Medicare carriers and found that only 15% of the time was the information both accurate and sufficient to answer the physician's questions. PPAC discussed this and will follow how CMS addresses this issue in the future.
Thank you for your time in reading this. Sincerely, Barbara L. McAneny, MD, FACP
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