Vol. 96, December 2023 DC E-Newsletter
Special Announcement
Please Complete the AMA Physician Practice Expense Survey
The American Medical Association’s (AMA) Physician Practice Information (PPI) Survey is underway, and the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS) urge all selected neurosurgeons to participate in this effort. The survey — endorsed by more than 170 organizations, including the CNS and the AANS — aims to collect updated and accurate data on practice costs (current data are 15 years old), a key element of Medicare physician payment.
Mathematica, a well-regarded consulting firm, is helping the AMA run this survey. Be on the lookout for an email from ppisurvey@mathematica-mpr.com and a United States Postal Service Priority Mail® packet from Mathematica containing a link to the survey and supporting information. We urge you to speak with your practice management colleagues to determine if they have received these communications and ask them to complete this critical survey.
Click here for more information about this survey.
Legislative Affairs
Efforts to Reform the Medicare Physician Payment System Continue
Efforts to advance legislation to prevent Medicare payment cuts and adopt long-term reforms continue, with Congress taking several steps on one of neurosurgery’s top advocacy priorities.
- Establishing an Automatic Inflation Update for Physicians. Earlier this year, Reps. Raul Ruiz, MD, (D-Calif.); Larry Bucshon,MD, (R-Ind.); Ami Bera, MD, (D-Calif.) and Mariannette Miller-Meeks, MD, (R-Iowa) introduced the Strengthening Medicare for Patients and Providers Act (R. 2474), which would put in place an annual physician payment update starting in 2024 based on the Medicare economic index (MEI). The MEI reflects increases in physician practice costs and would reverse a downward spiral of Medicare physician payments, which have failed to keep pace with inflation, jeopardizing the viability of physician practices and patients’ timely access to care.
- Reforming Medicare’s Budget Neutrality Rules. Under current law, policy changes in the Medicare Physician Fee Schedule (MPFS) each year that exceed $20 million requires an across-the-board decrease in payments to all physicians through reductions in the Medicare conversion factor. Over the years, this budget neutrality rule has led to significant cuts to specialists, including neurosurgeons. To help stabilize physician payments by improving how the Centers for Medicare & Medicaid Services (CMS) calculates the budget neutrality adjustment, House Doc Caucus members, including co-chairs Reps. Greg Murphy, MD, (R-N.C.); Brad Wenstrup, DPM, (R-Ohio) and Michael Burgess, MD, (R-Texas) teamed up with Rep. Robin Kelly (D-Ill.) to introduce the Provider Reimbursement Stability Act (R. 6371), which would reform the MPFS budget neutrality requirements. This bipartisan legislation would add crucial stability and predictability to Medicare physician payments by:
- Requiring CMS to reconcile inaccurate utilization projections based on actual claims;
- Raising the budget neutrality threshold from $20 million to $53 million and increasing it every five years by the cumulative increase in the MEI;
- Updating practice expense inputs, such as clinical labor costs, at least every five years; and
- Limiting the year-to-year conversion factor variance to no more than 2.5% each year.
On Oct. 31, the CNS and the AANS joined 120 national medical societies and state medical associations supporting this effort. Click here to read the medical groups’ letter.
- House Subcommittee Considers Medicare Proposals. On Oct. 19, the House Energy and Commerce Health Subcommittee held a legislative hearing titled “What’s the Prognosis?: Examining Medicare Proposals to Improve Patient Access to Care and Minimize Red Tape for Doctors.” The hearing featured several bills related to the MPFS. Click here for details.
Subsequently, on Nov. 15, the subcommittee advanced the Budget Neutrality Reform Bill (H.R. 6371) and H.R. 6369, which would extend incentive payments for physicians participating in eligible alternative payment models through 2026. During this hearing, Rep. Bucshon offered an amendment to provide physicians with an MEI-based inflationary update for 2024. Reps. John Joyce, MD, (R-Pa.) and Kim Schrier, MD, (D-Wash.) also teamed up to offer an amendment to prevent the entire 3.4% 2024 Medicare cut. Unfortunately, due to their costs, the amendments were withdrawn. Click here for details.
- Senate Finance Committee Advances Bipartisan Health Care Legislation. On Nov. 8, the Senate Committee on Finance advanced the Better Mental Health Care, Lower-Cost Drugs, and Extenders Act by a 26-0 vote. The legislation includes policies to address pending Medicare and Medicaid payment cuts. Specifically, this bipartisan legislation would eliminate scheduled Medicaid Disproportionate Share Hospital cuts for fiscal years 2024 and 2025 and mitigate an upcoming 3.4% Medicare Physician Fee Schedule cut by providing an additional 1.25% of relief (if adopted, the cut would be 2.15% instead). The bill would also extend advanced alternative payment model bonuses through calendar year 2026. Click here for details.
- House Committee Advances Bill to Mitigate Physician Payment Cuts. On Dec. 7, the House Committee on Energy and Commerce unanimously approved the Physician Fee Schedule Update and Improvements Act (H.R. 6545), as amended. Similar to the Senate Finance Committee measure, if adopted, this bill would provide an additional 1.25% of relief and reducing the cut to 2.15%.
- Legislation to Halt the 3.4% Physician Payment Cut Introduced. On Dec. 7, a bi-partisan group of legislators led by Reps. Greg Murphy, MD, (R-N.C.) and Danny Davis (D-Ill.) introduced the Preserving Seniors’ Access to Physicians Act (R. 6683). This bill would eliminate the scheduled 3.4% physician payment cut if enacted.
- CNS/AANS Washington Office Staff Featured in AMA Webinar. On Nov. 3, Katie O. Orrico, Esq., CNS/AANS senior vice president for health policy and advocacy, participated in an American Medical Association (AMA) Advocacy Insights webinar, “What’s next with Medicare payment reform.” Moderated by AMA board chair Willie Underwood III, MD, the webinar addressed where Medicare payment reform stands now, how the AMA, alongside state and national medical specialty societies, is pushing for permanent payment reform and ways for physicians to get involved in these advocacy efforts. Other participants included Ray Callas, MD, president-elect of the Texas Medical Association and Todd Askew, AMA’s senior vice president for advocacy. Click here to watch the webinar.
The CNS and the AANS will continue their efforts to prevent Medicare cuts next year and adopt longer-term reforms. To this end, on Nov. 6, the neurosurgical societies joined two coalition efforts urging Congress to stop the 3.4% pay cut. Click here and here to read the letters. Additional information and resources are available at the AMA’s Fix Medicare Now website.
CNS and AANS Continue Advocating for Prior Authorization Reform
Last year, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule requiring Medicare Advantage plans and other public health insurers to implement automated prior authorization systems. This proposal would:
- Require insurers to adopt electronic prior authorization;
- Reduce care delays and improve patient outcomes by ensuring that health plans respond to prior authorization requests within specific timeframes (72 hours for urgent requests and seven days for standard requests);
- Require coverage determinations to be reviewed by professionals with relevant expertise;
- Support efforts (e.g., gold cards) to waive or modify prior authorization requirements based on provider performance; and
- Compel health plans to publicly report the use of prior authorization, including information on delays and denials.
The proposal has cleared CMS and awaits final approval from the White House. This proposed rule mirrors the key policies of the Improving Seniors’ Timely Access to Care Act (H.R. 3173/S. 3018 in the 117th Congress), which unanimously passed the House of Representatives and garnered 380 combined bipartisan co-sponsors. The CNS and the AANS hope the proposal will be finalized before the end of the year.
On the legislative front, the CNS and the AANS recently joined the Regulatory Relief Coalition (RRC) in sending a letter thanking Reps. Brett Guthrie (R-Ky.) and Anna Eshoo (D-Calif.) for including the Seniors’ Timely Access to Care Act at the recent House Committee on Energy and Commerce health care hearing. Following the hearing, on Oct. 19, the RRC issued a press release featuring CNS/AANS Washington Committee chair Russell R. Lonser, MD, FAANS, who stated “America’s neurosurgeons urge CMS to release final rules to streamline prior authorization and for Congress to get this legislation across the finish line this year because patients can ill afford to wait any longer to hold Medicare Advantage plans accountable.”
Finally, as previously reported, on July 26, the House Ways and Means Committee advanced legislation — the Health Care Transparency Act (H.R.4822) — to reform prior authorization in the Medicare Advantage (MA) program. The bill included the neurosurgery-backed Improving Seniors’ Timely Access to Care Act.
Neurosurgery Responds to RFI on Solutions to Improve Outcomes and Reduce Federal Health Care Spending
On Oct. 15, the CNS and the AANS joined the Alliance of Specialty Medicine (Alliance) and Regulatory Relief Coalition (RRC) in responding to a House Budget Committee Health Care Task Force Request for Information seeking input on solutions to improve outcomes and reduce federal health care spending. The groups recommended that Congress:
- Provide an annual inflationary update for Medicare physician payment tied to the Medicare Economic Index;
- Adopt prior authorization reforms in the Medicare Advantage program and address overpayments to Medicare Advantage plans;
- Require physicians practicing in the same specialty or sub-specialty review Medicare denials;
- Ensure that the Quality Payment Program offers physicians more clinically relevant participation pathways and streamlines the program to reduce reporting burdens;
- Recognize that specialists provide procedures and services that save lives and reduce health care costs; and
- Modernize the way the Congressional Budget Office estimates the cost of legislation.
Click here to read the Alliance letter and here for the RRC letter.
Neurosurgery Supports Telehealth Expansion Legislation
On Oct. 31, the CNS and the AANS joined more than 165 organizations in sending letters to the House and Senate leaders supporting the passage of the Telehealth Expansion Act (H.R. 1843/S. 1001). This bipartisan legislation would make permanent the pandemic-era policy that enabled employers to provide telehealth services on a pre-deductible basis to individuals with high-deductible health plans coupled with a health savings account. On June 7, the House Committee on Ways and Means advanced the bill to the full House of Representatives.
Click here to read the House letter and here for the Senate letter.
Gabriella Miller Kids First Research Act 2.0 Legislation Approved by Senate Committee
On Sept. 21, the Gabriella Miller Kids First Research Act 2.0 (S. 1624) was approved by the Senate Committee on Health, Education, Labor and Pensions (HELP). Introduced by Sens. Tim Kaine (D-Va.) and Jerry Moran (R- Kan.), this legislation would expand the available funds to support research on pediatric diseases and disorders at the National Institutes of Health (NIH). The CNS and the AANS previously sent letters of support to the Senate and House. Earlier, the House Committee on Energy and Commerce approved the companion bill (H.R. 3391) on Aug. 25, and it is awaiting action.
Coding and Reimbursement
Neurosurgery Leads Amicus Brief in Surprise Medical Billing Case
Continuing their advocacy to ensure that the Biden Administration implements the law as written and intended by Congress, on Sept. 18, the CNS and the AANS, along with the Physician Advocacy Institute and several state and national medical associations, spearheaded an amicus brief in the Texas Medical Association’s (TMA) second lawsuit (TMA II) challenging elements of the NSA. The government has appealed the TMA II ruling, which favored physicians.
Under the No Surprises Act, physicians and insurers can use an independent dispute resolution process to resolve out-of-network payment disputes. The process was intended to keep patients out of the middle of these billing disputes. Unfortunately, the final rule implementing the law unfairly favors insurers.
CMS Releases 2024 Medicare Physician Fee Schedule Final Rule
On Nov. 2, the Centers for Medicare & Medicaid Services (CMS) released the 2024 Medicare Physician Fee Schedule Final Rule. The 2024 conversion factor is $32.7442, reduced by 3.37% from the 2023 conversion factor of $33.8872. CMS estimates that neurosurgeons’ overall reimbursement will decrease by one percent in addition to the conversion factor reductions.
Highlights from the final rule include:
- Split/Shared Billing Changes. CMS finalized a change in its definition of the “substantive portion” of a visit for services furnished in a facility setting by a physician and non-physician practitioner (NPP) from the same group practice. Following an updated and clarified definition published by the American Medical Association Current Procedural Terminology (CPT®) that states the substantive portion of an evaluation and management (E/M) visit is more than half of the total time spent by the physician and NPP performing the split (or shared) visit or a substantive part of the medical decision making (MDM). The CNS and the AANS supported allowing reporting of the visits based on MDM rather than time alone.
- G2211 Office/Outpatient E/M Visit Complexity Add-On HCPCS Code. Despite objections from the CNS, AANS and other stakeholders, CMS finalized its proposal to activate the G2211 complexity add-on code. Absent Congressional action to halt implementation of this code, it will go live on Jan. 1, 2024. Earlier this fall, the CNS and the AANS had led coalition efforts in the House and Senate advocating that the code is unnecessary and the estimated utilization was too high. This code is mainly responsible for the 2024 Medicare physician payment cut.
- Code Values for New/Revised Services. CMS accepted the RVS Update Committee-passed values for most of the new neurosurgical codes, including a new code set for skull-mounted cranial neurostimulator codes.
A press release and fact sheet provide more information about the final rule.
CMS Releases CY 2024 Medicare Hospital OPPS and ASC Final Rule
On Nov. 2, the Centers for Medicare & Medicaid Services (CMS) released the 2024 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule. The 2024 OPPS final rule sets a 3.1% increase in OPPS payment rates to hospitals and ASCs that meet relevant quality reporting requirements. CMS also adopted neurosurgery-supported provisions, including:
- Adding new codes for vertebral body tethering (CPT codes 22836, 22837 and 22838) and inserting skull-mounted cranial neurostimulator pulse generator or receiver (CPT code 61889) to the inpatient-only (IPO) list;
- Refraining from adding codes to the current list of service categories subject to prior authorization; and
- Rejecting measures under the Hospital Outpatient Quality Reporting Program and the ASC Quality Reporting Program that evaluate facility volume on outpatient and ASC surgical procedures (the CNS and the AANS had expressed concerns about volume being an appropriate quality indicator).
Additional information is available:
CMS Issues Expanded Medicare Coverage for Carotid Artery Stenting
On Oct. 11, CMS issued a final National Coverage Decision (NCD) decision memo on Carotid Artery Stenting that agrees with the position raised by neurosurgery in an Aug. 4 letter to the agency. Specifically, the updated policy would:
- Expand coverage to individuals previously only eligible for coverage in clinical trials;
- Expand coverage to standard surgical risk individuals by removing the limitation of coverage to only high surgical risk individuals;
- Remove facility standards and approval requirements;
- Add formal shared decision-making documentation with the individual before furnishing CAS; and
- Allow Medicare Administrative Contractors discretion for all other coverage of percutaneous transluminal angioplasty of the carotid artery concurrent with stenting not otherwise addressed in the NCD.
Neurosurgery Comments on Draft Coverage Policy for Intraoperative Neurophysiological Monitoring
On Sept. 24, the CNS, AANS and CNS/AANS Joint Section on Disorders of the Spine and Peripheral Nerves sent a letter in response to a North American Spine Society (NASS) draft coverage policy for Intraoperative Neurophysiological Monitoring (IONM) in spine surgery. Neurosurgery generally agreed with the NASS draft proposal but emphasized that oversight of IONM should be limited to physicians, as supported by American Medical Association and Centers for Medicare & Medicaid Services policy.
Communications
Neurosurgeons Featured in Article on Prior Authorization in Spine Surgery
On Sept. 25, Becker’s Spine Review published an article titled, “‘No other industry would tolerate this: The problem with prior authorization in spine surgery.” Neurosurgeons Anthony M. DiGiorgio, DO, MHA, FAANS; Praveen V. Mummaneni, MD, FAANS and Luis M. Tumialán, MD, FAANS, discuss prior authorization and the significant problems physicians face when it comes to receiving fair payments for services offered. Denial of payment after prior authorization has become a grim reality in American health care. Insurance companies authorize procedures, and surgeons perform them as approved. Then, the insurance company denies payment. Patients ultimately bear the brunt of this charade, the authors state.
On Oct. 6, Neurosurgery Blog published a cross-post to amplify the message.
Neurosurgeons Featured in Article on Coverage for Spine Care
On Oct. 2, Becker’s Spine Review published an article titled, “‘Its position has become untenable’: Why 3 neurosurgeons are fed up with Aetna.” While Aetna has taken steps to expand its coverage for spine and orthopedic care in the last year, it is still not enough for some surgeons. Neurosurgeons Anthony M. DiGiorgio, DO, MHA, FAANS; Praveen V. Mummaneni, MD, FAANS and Luis M. Tumialán, MD, FAANS, issue a statement on their frustrations with Aetna and the fights many surgeons have been enduring with the insurer for years over a particular type of spine implant.
Neurosurgery Blog Features Article on Medicare Physician Payment System
On Oct. 25, the Neurosurgery Blog cross-posted a recent publication in The Hill by Reps. Larry Bucshon, MD, (R-Ind.); Ami Bera, MD, (D-Calif.); Raul Ruiz, MD, (D-Calif.) and Mariannette Miller-Meeks, MD, (R-Iowa). Titled “Fix the broken Medicare physician payment system that threatens patient access,” the op-ed states that the Medicare payment system fails to reimburse physicians adequately for the critical services they provide. Unlike other providers, the Medicare Physician Fee Schedule does not have an automatic inflationary update, and physician payments declined by 26%from 2001 to 2023 when adjusted for inflation.
Neurosurgeon Featured in Article about Prior Authorization
On Nov. 1, Becker’s Orthopedic Review published an article titled, “UnitedHealthcare’s prior authorization removals just ‘payer antics,’ surgeons say.” While UnitedHealthcare has eliminated several spine surgery services from prior authorization, surgeons have not seen any real benefit from the removal. California neurosurgeon Brian R. Gantwerker, MD, FAANS, notes:
I have not seen any changes regarding prior authorization elimination. If anything, I imagine it is a ploy to try to muddy the waters. Hospitals and physicians have experienced terrible amounts of denials and unfair withholding of payments and clawbacks. I imagine that there is a new, more sinister technique that they will use in order to get around the prior authorization bills coming through Congress, and this is just a poorly spirited attempt. The next phase of payer antics I’ve seen is prepayment reviews, which technically get around the prior authorization process by having physicians perform the service after getting prior authorization, but then denying payment after the service has been completed. This obviously provides some window to get around privatization laws and “be compliant.” Until the Office of Inspector General and the Federal Trade Commission enforce existing laws around insurance companies, we will never see improvement.
Neurosurgery Blog Begins Series on Making and Maintaining a Neurosurgeon
Neurosurgery Blog recently began a new series focusing on becoming a neurosurgeon.
Read the first three articles in the series:
Please Share Your Social Media Handles
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Click here to provide us with your public social media account handles.
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