NEWS ALERT

JANUARY 4, 2021

 Fairfield County Medical Association
917 Bridgeport Avenue, Shelton, Connecticut
Tel: (203) 513-2045 / Fax: (203) 513-8036
Website: www.fcma.org / Email: info@fcma.org
COVID-19 RELIEF PACKAGE
The President signed into law the COVID-19 relief package that he had previously threatened to veto. The measure contains a number of far-reaching proposals that impact physicians, including helping to prevent or reduce significant Medicare cuts that physicians were going to receive; another $284 billion for the Paycheck Protection Program for small businesses, including physician practices who may have already received a PPP loan/grant; ensuring that receipt of a PPP loan/grant will not prevent a business from deducting expenses it might otherwise have deducted; and funding for an additional 1,000 medical residency positions. It also includes the federal provisions for addressing surprise out-of-network bills, which had been improved but still contained significant problematic provisions.. 
Congressional Package Helps to Prevent or Reduce Medicare Cuts

As a result of an advocacy effort across the entirety of the medical profession, the year-end Congressional package –that was signed into law – take a number of steps to help prevent and/or reduce what would have been enormous cuts to Medicare payments to many physician specialties. Specifically, it will:
 
  • Provide for a one-time, one-year increase in the Medicare physician fee schedule of 3.75%, to support physicians and other professionals in adjusting to changes in the Medicare physician fee schedule during 2021, and to provide relief during the COVID-19 public health emergency.
  • Delay for 3 years the Secretary’s implementation of Code G2211 which reportedly would have increased the MPFS by approximately 3%.
  • Delay the negative2% sequestration cuts for 3 months.
 
As noted in this chart developed by the AMA the impact of the actions by specialty is summarized. Examples are as follows:
 
  • Under the original CMS Medicare 2021 payment rule, ophthalmologists were expected to see a 6% cut, but now will face likely no cut.
  • Under the original CMS Medicare 2021 payment rule, general surgeons were expected to see a 6% cut, but now will face likely no cut.
  • Under the original CMS Medicare 2021 payment rule, neurosurgeons were expected to see a 6% cut, but now likely will face no cut.
  • Under the original CMS Medicare 2021 payment rule, interventional radiologists were expected to see an 8% cut, but now it will be a likely 2% cut.
  • Under the original CMS Medicare 2021 payment rule, internal medicine was expected to see a 4% increase, but now likely a 6% increase.
  • Under the original CMS Medicare 2021 payment rule, anesthesiology was expected to see an 8% cut, but now likely a 2% cut.
  • Under the original CMS Medicare 2021 payment rule, PM&R was expected to see a 3% cut, but now likely will have a 3% increase.

Importantly, the long overdue E&M changes set forth in the CMS 2021 Medicare payment rule will go forward.
Congressional Package Includes Expansion of Paycheck Protection Program (PPP)

The Congressional year end package included an additional $284 billion for the Paycheck Protection Program (PPP). Importantly, it will enable a second PPP forgivable loan for the hardest-hit small businesses (including physician practices) and non-profits with 300 or fewer employees which can demonstrate a loss of 25% of gross receipts in any quarter during 2020 when compared to the same quarter in 2019.
 
It will also provide that loans will not be included in taxable income, and clarifies that deductions are allowed for expenses paid with proceeds of a forgiven PPP loan, effective as of the date of enactment of the CARES Act and applicable to subsequent PPP loans. Several physicians were concerned that receipt of a PPP loan/grant was going to cause them to not be able to deduct business expenses due to a recent IRS interpretation.

The new law will also provide for an additional $20 billion for EIDL Advance Grants. Small businesses and nonprofits in low-income communities are eligible to receive $10,000 grants. Previous recipients are also eligible to receive the full $10,000 if their award was less in the first round of grants.

Read here for a comprehensive AMA summary of this and many other provisions in the Congressional COVID relief package.
Congress Passes Measure to Address Surprise Medical Bills – Improvements Over Earlier Version but Still Tilted in Favor of Insurance Companies
 
Among the provisions contained in the year-end Congressional COVID relief package is a comprehensive measure to establish a federal standard for addressing surprise out-of-network medical bills.

Based upon initial review and conversations with Congressional staff and the AMA, the new federal surprise bill provisions will apply to patients insured by ERISA plans.

The measure will ensure that patients are “held harmless” from surprise out-of-network medical bills.  Patients will only be required to pay the in-network cost-sharing, (i.e., copayment, coinsurance, and deductibles) amount for out-of-network emergency care, for certain ancillary services provided by out-of-network providers at in-network facilities, and for out-of-network care provided at in-network facilities without the patient’s informed consent.

The federal provision calls for a 30-day open negotiation period for out-of-network physicians and payers to settle out-of-network claims and, if the 30 day negotiation period is unsuccessful, requires either the physician or the health plan to initiate an independent dispute resolution (IDR) process within 4 days of the end of the 30-day period.

The federal IDR entity will determine which side – the physician’s or the insurer’s suggested payment – will prevail. Physicians may batch similar services in one proceeding when claims are from the same payer, but the bill permits only 30 days of batching. The IDR entity would consider numerous sources of information brought by either party, such as the provider’s training and experience, patient acuity, and the complexity of furnishing the item or service. However, neither provider charges nor usual and customary charges may be considered by the IDR entity, and the IDR entity is required to consider the market-based median in-network rate. This a major deficiency that was highlighted in advocacy efforts over the last year.

There were improvements including a prohibition of the consideration of Medicare or Medicaid data by the IDR, as well as elimination of provisions that would have set up cumbersome processes to require patients to receive a detailed description of services rendered within 15 days of the date of service and required a patient to be billed within 90 days of the date of service even if the claims had not been fully adjudicated by the health insurer.

The Congressional provisions also address “voluntary” out-of-network services by providing that non-participating providers at participating facilities may not bill a patient more than the cost-sharing requirements or balance bill the patient unless the notice and consent requirements are met. These consent requirements include providing the patient with written notice and consent 72 hours in advance of appointment; providing a good faith estimate of the costs of the services; and providing the patient with a list of in-network providers at the facility and information regarding medical care management, such as prior authorization. At participating facilities, the notice and consent exception does not apply to out-of-network providers of radiology, pathology, emergency, anesthesiology, diagnostic and neonatal services; assistant surgeons, hospitalists, intensivists, and providers offering services when no other in-network provider is available.

Further analysis of this far-reaching legislation is ongoing, so remain alert for further updates.