National Coverage Determination (NCD) Dashboard Now Available
Currently, there are 8 topics on the NCD wait list, 2 topics on the open NCD list and 4 NCDs finalized in the past 12 months.
CMS prioritizes NCD requests based on the “magnitude of the potential impact” for Medicare beneficiaries and the program alike. It recognizes the need for streamlining and standardizing the NCD review process whenever possible. Utilization of this document is a quick and concise way to review specific topics during various stages in the NCA process. Importance of PPIS Data for MPFS Adjustments
The American Medical Association (AMA) Physician Practice Information Survey (PPIS) is sent out to radiology practices and other specialties to collect practice cost information and hours spent in direct patient care. This information is shared with the Centers for Medicare and Medicaid Services (CMS), which is then used to help update the Medicare Economic Index (MEI) and Resource Based Relative Value Scale (RBRVS). Overall, this process will significantly impact the annual Medicare Physician Fee Schedule (MPFS).
The last PPIS data for radiology was collected in 2007, and only 105 radiology practices participated. Of those responding, only 21 practices filled out the entire survey and validated they had direct practice expenses. The data collected is considerably outdated and needs to be current to represent costs for physicians in practices. The AMA has contracted with an independent research and analytics firm, Mathematica, to conduct the current PPIS, including the timelines involved in data collection and analysis; sample size, including data sets to represent a mix of specialties, reporting and use of data; and communication to prospective participants. This survey has been promoted since June 2023. The American College of Radiology (ACR) is one of 173 medical groups recommending its members participate in the PPIS to ensure the data collected will accurately represent their practices, patients and profession. In a statement, the ACR urged members whose practices were selected to participate in the PPIS to complete the survey as soon as they receive it, as the end of June deadline is quickly approaching. The ACR also provided Mathematica’s email for members to obtain the survey link. FDA Provides List of AI-Enabled Devices
The Food and Drug Administration (FDA) recently published an updated list of approved/cleared Artificial Intelligence and Machine Learning (AI/ML) enabled devices that have been marketed in the United States across multiple medical specialties. These devices have met the FDA’s related premarket requirements, including a “focused review of the devices’ overall safety and effectiveness, which includes an evaluation of appropriate study diversity based on the device’s intended use and technological characteristics.”
Although the approvals/clearance of these types of devices have increased in recent years, the Centers for Medicare and Medicaid Services (CMS) has only assigned payment for about 10 of these device applications. In response, several patient advocacy groups recently requested Congress to address this issue with CMS by encouraging creation of a formalized payment pathway for AI/ML devices. Known as Algorithm-Based Healthcare Services, it is anticipated to be published in the 2025 Hospital Outpatient Prospective Payment Systems (OPPS) proposed/final rules.
CMS Preparing to Close Change Healthcare Cyberattack Financial Relief Program
In a June 17 press release, the Centers for Medicare and Medicaid Services (CMS) announced that payments under the Accelerated and Advance Payment (AAP) Program for the Change Healthcare/Optum Payment Disruption (CHOPD) will stop accepting new applications on July 12, 2024. The program, which began in March, was created to offset cash flow interruptions to Medicare providers and suppliers due to the Change Healthcare Cyberattack in February of this year.
According to CMS, CHOPD has provided accelerated and advanced payments totaling more than $2.55 billion to 4,200 Part A providers; and more than $717.18 million to 4,722 Part B providers and suppliers. To date, CMS said it has recovered over 96% of the CHOPD payments as a result of providers and suppliers effectively billing and receiving Medicare payments. Providers and suppliers are encouraged to contact Change Healthcare and/or their Medicare Administrative Contractor (MAC) for all billing and reimbursement issues they still may be experiencing. In the face of one of the most widespread cyberattacks on the U.S. health care industry, CMS promptly took action to get providers and suppliers access to the funds they needed to continue providing patients with vital care,” said CMS Administrator Chiquita Brooks-LaSure. “Our efforts helped minimize the disruptive fallout from this incident, and we will remain vigilant to be ready to address future events.” House Energy and Commerce Subcommittee Holds 340B Oversight Hearing
On June 4, the House Energy and Commerce Oversight and Investigations subcommittee hosted a hearing to discuss oversight of the 340B Drug Pricing Program, including testimony from policy researchers and providers.
“It’s important that we preserve patients’ access to important and live-saving drugs. We must explore how the 340B program is working to ensure it aligns with how the program was intended to function,” said the subcommittee Chairs Rodgers and Griffith. “This hearing will give Members an opportunity to hear from industry experts about how the 340B program is working and, if necessary, how it could be improved.” The 340B program was created to support hospitals and other covered entities (CEs) that care for a disproportionate number of low-income populations. The program allows these CEs to purchase certain outpatient drugs from manufacturers at a reduced cost. The savings from these reduced costs are intended to be passed to patients through reinvestment in the community to help provide additional patient care and resources. There is little mandated reporting in 340B, as CEs are not required to report how they use the revenue from the program. As the 340B program participation is expanding, so is the concern that CEs are profiting from the savings rather than reinvesting into the community and patient care. A 2023 review published in the JAMA Health Forum revealed some studies suggested CEs use revenue from the program as intended, while other studies suggested CEs use revenue from the program for financial gain to acquire physician practices and open new sites in high income areas. Throughout the hearing, there was overall support for continuation of the 340B program. However, members and witnesses agreed the program needs transparency to ensure the program's intent is carried out by all participating entities.
There were witness suggestions for improving transparency in the program, including:
MedPAC Recommendations for MPFS
As part of its government mandate, the Medicare Payment Advisory Commission (MedPAC) released its report to Congress, containing six chapters for Medicare Physician Fee Schedule (MPFS) recommendations. As taken directly from the June 2024 MedPAC Report to Congress:
The commission has suggested the 2025 payment rates remain “flat”, but starting in 2026, will increase 0.75 percent per year for qualifying physicians participating in A-APMs, and will increase by 0.25 percent per year for all other physicians. The commission has also expressed its concern whether physician payments will be sufficient in the future. From an inflation standpoint, the Medicare Economic Index (MEI), which measures practice cost information and hours spent in direct patient care, is expected to increase an average of 2.3 percent per year from 2025 through 2033. This increased growth would exceed the increases in the MPFS rates. The commission goes on to say this gap would incentivize physicians to either reduce the number of Medicare patients they treat; or stop participation in the Medicare program entirely. Moreover, the difference in payment rates when a service is billed in a freestanding physician office versus a hospital outpatient department (HOPD) could incentivize performance and billing of services in the higher reimbursed HOPD setting. The commission offered alternative approaches to updating the payment rates to include updating the practice expense portion of the PFS payment rates by the hospital market basket, adjusted for productivity, and updating the total PFS payment rates by the MEI minus 1 percentage point. The commission pointed out the first approach would require significant operational changes in the way payments are set and updated over time; while the second approach would be simpler to implement, including the reduction or elimination of policymakers to reassess PFS policy in the future. The commission believes the second approach to be “more desirable and will continue to develop this option in the future.” Senate Bill Reintroduced to Lessen Burden of Prior Authorization Requirements for Medicare Advantage Plans
A republican Senator from Kansas, Roger “Doc” Marshall, MD, led the reintroduction of bipartisan legislation that would lessen current prior authorization requirements. The bill, known as the Improving Seniors’ Timely Access to Care Act of 2024 is supported by almost 400 organizations across the country, including the American College of Radiology, Association of Academic Radiology, Society of Interventional Radiology and the American Society of Neuroradiology. A section-by-section summary of the bill can be read here.
In a statement, Senator Doc Marshall, who is also an Obstetrician, said “Prior authorization is the number one administrative burden facing physicians today across all specialties. As a physician, I understand the frustration this arbitrary process is causing healthcare practices across the country and the headaches it creates for our nurses. With the bipartisan, bicameral Improving Seniors’ Timely Access to Care Act, we will streamline prior authorization and help improve patient outcomes and access to quality care and life-saving medicine.” An analysis published in the JAMA Health Forum found the top three specialties with the highest rate of services that require prior authorization to be Cardiology, Radiation Oncology, and Radiology. Improvements to the prior authorization process provided in this bill will have a direct impact on patient care for these specialties. Concerns about the prior authorization process have been raised by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) since 2018. An audit conducted by the OIG found Medicare beneficiaries and providers rarely used the appeal process, but when they did Medicare Advantage plans overturned 75% of denials. This high rate of overturned denials, combined with the low rate of beneficiaries and providers that utilized the appeal process (only 1 percent of denials were appealed to the first level in 2014 – 2016), raised concerns about Medicare beneficiaries receiving timely access to care for benefits that should have been provided. The OIG also released a report in 2022 which found Medicare Advantage plans “denied prior authorization and payment requests that met Medicare coverage rules.” The Improving Seniors’ Timely Access to Care Act was unanimously passed in the U.S. House of Representatives in 2022, but roadblocked by the Senate due to a high cost of implementation. The new bill has a reduced score from the Congressional Budget Office (CBO). Senator Doc Marshall stated, “With the improvements we’ve made there is no reason we should not quickly get this bill signed into law.” In a news release, the ACR stated it “is pleased to see this legislation reintroduced and looks forward to working with policymakers to address prior authorization.” The House and Senate have also received positive recognition for reintroducing the Improving Seniors’ Timely Access to Care Act from the American Hospital Association (AHA). The AHA sent letters of praise to leaders in the House and Senate. Executive Vice President, Stacey Hughes, stated “The AHA greatly appreciates the leadership from this bipartisan group of Senators and Representatives by reintroducing vital legislation to streamline the broken prior authorization process in the Medicare Advantage Program. By removing unnecessary barriers that create delays in treatment, this meaningful bill will improve access to patient care for seniors and allow caregivers to spend more valuable time at the bedside with patients and less time on burdensome paperwork.”
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