Archive | November 2013

UHC Medicare Advantage Physician Terminations-Organized Medicine Urges that Recent Terminations be Held in Abeyance

MSNJ continues to send appeal letters to CMS and request that it test network adequacy on a case-by-case basis. Please continue to provide information to MSNJ.

MSNJ met with representatives from UHC this week at our offices in Lawrenceville. One of our continuing concerns is how UHC will communicate with its Medicare Advantage members concerning its network reduction initiative and whether Medicare patients will know if their physician will be in the network in 2014. UHC responded that:

Members with recent claims for physicians leaving the network will receive a letter from UHC at least 30 days before the effective date of the termination with instructions to call the customer service number for more information. UHC currently estimates member mailings to take place in early November. Timelines are not yet final for member mailing dates, and are subject to change as data analysis is completed and information finalized.

Consequently, the timing of UHC communication with patients may be as late as the end of the year according to the above information. We are disappointed  because the open enrollment period will have ended and it will be too late for patients to make choices based on the physicians who will remain in these plans. To address this ongoing transparency concern, and the ability of Medicare patients to make informed choices to keep their physician if they wish to, MSNJ joined with the AMA and virtually all of organized medicine requesting that CMS require Medicare Advantage plans to hold all terminations initiated just prior to or during Open Enrollment in abeyance for cost year 2014. Read the letter to CMS which asks that it extend the Medicare Advantage open enrollment period and require plans that have reduced their networks to:

1)     Provide and document that patients received actual and accurate notice of whether their current physicians will be in the 2014 network;

2)     Ensure that patients know that they can retain their physician by choosing fee for service or by choosing a product with an out-of-network benefit if their plan provides one.

3)     Provide physicians information needed to challenge network adequacy based on CMS regulations and extend the appeals deadline until physicians receive such information;

4)     Provide information on how many patients have been impacted and which physicians to state medical societies and the AMA; and,

5)     Direct plans to hold all terminations initiated just prior to or during Open Enrollment in abeyance for cost year 2014.

In addition to our disappointment about UHC’s plans for the timing and communication with patients, UHC also advised this week that it would not carve out an exception for patients who wish to continue to be treated by physicians who may be terminated. UHC will provide us with its continuity of care policy.

UHC advised that physicians should contact their provider representatives to discuss staying in the network. We have posted an updated provider representative list on our web site for members who wish to do so. Since we cannot anticipate how successful these conversations may be, we recommend that physicians appeal from network terminations and supplement pending appeal letters with new information. Visit MSNJ’s web site for appeal pointers. Members should visit the web site for additional resources. We continue to send appeal letters to CMS and ask that it test network adequacy on a case-by-case basis. Please continue to provide information to MSNJ.

House & Senate Committees Issue Framework for Repealing Medicare’s SGR

Late last week, the House Ways & Means and Senate Finance Committees issued a discussion draft on how to repeal the Medicare SGR and reform physician payments. The discussion draft is a summary of the House and Senate’s bicameral framework to repeal and replace the SGR, the first and most significant work from Congress on this decade old problem. Unless Congress acts before January 1, the Medicare physician payment schedule will be reduced on average by 24%.

Key provisions:

  • The SGR formula is repealed.
  • Annual fee schedule payment updates would be frozen for 10 years; annual positive updates would begin in 2024.
  • A new “value-based performance (VBP) payment program” would be used to adjust payments beginning in 2017.  This new VBP program essentially combines all the current incentive and penalty programs (e.g., value-based modifier, meaningful use, PQRS) into one budget-neutral program.  Payments could be increased or decreased significantly, depending on how well a physician scores relative to others on a composite performance score.
  • Physicians participating in certain alternative payment models, including the patient-centered medical home, would be exempt from the VBP program.  Revenue thresholds are established for APMs other than the medical home model, and two-sided risk and a quality component would be required to qualify for a 5% bonus in 2016-2021.
  • Several proposals to “ensure accurate valuation of services” under the physician fee schedule are made.  Over a three-year period, mis-valued codes would have to be adjusted to achieve 1% in total fee schedule savings to avoid reductions in the total physician payment pool.  In addition, the Secretary of HHS would initiate a data collection effort on resource use requiring selected physicians to submit data (CMS may provide some compensation to physician for doing this) or face a one-year, 10% payment reduction.
  • Appropriate use criteria would be applied to certain imaging services; prior authorization requirements would be imposed on outliers.
  • HHS would publish utilization and payment data for physicians on the Physician Compare web site.

Comments are sought by the committees by November 12. MSNJ is evaluating and conferring with the AMA on the discussion draft. This will be a topic of debate at the AMA Interim Meeting next week. It is important to note that the draft is not legislation and provisions included in the draft could change.