January 7, 2021
1. Medicare Releases Updated Physician Fee Schedule

2. TOA's Circle of Champions for 2021: Thanks for Their Support

3. Texas' e-Prescribing Waiver for 2021: It's Available

4. Surprise Medical Billing Settled at the Federal Level

5. Payers Push Back on Federal Prior Authorization Reforms
6. Distribution of Third Round of HHS's Provider Relief Funds

7. New Round of PPP Loans

8. TOA Files Amicus Brief in TX Supreme Court Personal Injury Case

9. TOA's 2021 Texas Legislature Bill Tracker

10. Upcoming ODG and Workers' Comp Webinars
Zoom: Practice Opportunities for Orthopaedic Residents
Friday, February 5 | 6 a.m. - 7 a.m. CST | Click Here

TOA is now offering two free hours of online CME to fulfill the state's new opioid prescribing CME mandate. Click here to access it. Click here to view the newest CME requirements in Texas.

1. Medicare Releases Updated Physician Fee Schedule
Medicare released the updated physician fee schedule earlier today. The payment update was mandated by Congress' end-of-year legislation that addressed the E/M cuts, banned surprise billing for emergency services, and created a new round of PPP.

Click here to view TOA's web page that includes Medicare's updated fee schedule. Keep checking this page over the next week; TOA will continue to update this page with new items.

Again, thanks to all of the orthopaedic surgeons who made phone calls to Members of Congress to ask them to support the efforts to defeat Medicare's Physician Fee Schedule cuts for E/M.

Per CMS earlier today:

On December 27, the Consolidated Appropriations Act, 2021 modified the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS):

  • Provided a 3.75% increase in MPFS payments for CY 2021
  • Suspended the 2% payment adjustment (sequestration) through March 31, 2021
  • Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023
  • Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024

CMS has recalculated the MPFS payment rates and conversion factor to reflect these changes. The revised MPFS conversion factor for CY 2021 is 34.8931. 
2. TOA's Circle of Champions:
Thanks to Our Sponsors
This year will be different for TOA: We will continue to watch the pandemic's course to determine whether or not we can hold a smaller meeting in the fall.

In the meantime, TOA's reliance on sponsorship revenue to support TOA's important advocacy work does not change. As a result, TOA is grateful to our 2021 Circle of Champions, which gave their commitment to TOA's work (whether TOA is able to hold a conference or not in 2021).
3. Texas' e-Prescribing Waiver for 2021 Coming Within Days
The Texas Medical Board (TMB) has already granted some e-prescribing waivers. TOA has also had questions about pharmacists who have denied paper scripts.

Click here to learn more about the new e-prescribing mandate in the state of Texas.

The new law was created by HB 2174 in the 2019 Texas Legislature:

  • Prescribers may seek a one-year waiver on the grounds that the mandate creates financial or technical hardships.
  • A pharmacist is not required to verify that a prescription is exempt from the e-prescribing mandate.

The new law was pushed by the state's attorney general, Ken Paxton.
4. Surprise Medical Billing Settled at the Federal Level
Congress finally settled the surprise billing for out-of-network services debate at the federal level. Congress' end-of-year legislation, which was signed into law, contained surprise billing measures that closely resemble the Texas law that went into effect in 2019:

  • A ban on surprise billing the patient for emergency services. (Surprise billing/balance billing is viewed as a bill that is sent above and beyond the deductible, co-insurance, and co-pay.)
  • Surprise billing for elective care will still be allowed for instances in which a patient signs off on disclosures from physicians.
  • Surprise billing will still be allowed for ground ambulances. Both state and federal lawmakers recognized that the taxpayer would have to assume the bill if a patient did not pay for the cost of his or her transport.

The surprise billing deal closely resembles the proposal that TOA sent to TOA members in mid-December - click here to review it. The major change between mid-December and the final law was the agreement to exclude Medicare and Medicaid rates from what an arbitrator may consider when determining a fair rate for the out-of-network service.

Texas Law vs. Federal Law
The 2019 Texas law - SB 1264 - only affects commercial health plans that are regulated by the state: individual plans (Obamacare), some small group, and state employee plans. Meanwhile, the federal government regulates ERISA plans, which represent the vast majority of commercial health plans sold in Texas.

Physician groups pointed to the state laws in Texas and New York as the ideal ways to address out-of-network bills. Both states center their out-of-network policies on a baseball-style arbitration process in which an arbitrator determines the fair payment.

How Do I Learn More?
Click here to view TOA's web page that covers the provisions in the end-of-year legislation. TOA will continue to update this page with more summaries as they become available.
5. Payers Push Back on Federal Prior Authorization Proposals
TOA told you in last month's e-mail update about the federal government's proposed prior authorization reforms in December. Information about prior authorization issues in both Austin and Washington from TOA's December newsletter can be found below.

The health plans have pushed back against the federal government's prior authorization proposals. Click here to learn more.

From TOA's December 2020 Newsletter:

Texas Senator Kelly Hancock (R-North Richland Hills) and Rep. Tom Oliverson, MD (R-Spring) asked stakeholders to submit legislative recommendations for the 2021 Texas Legislature.

Click here to view TOA's recommendations.

Some of TOA's recommendations include:

  • Require the health plans to include their medical policies on their web page.
  • Create a timeline for prior authorization decisions.
  • Create an electronic prior authorization program so that staff members are not placed on a telephone hold for hours at a time.

Federal Proposal
The Centers for Medicare and Medicaid Services (CMS) proposed a new prior authorization rule on December 10 that would affect Medicaid, Children's Health Insurance Program, and Qualified Health Plan payers. However, qualified health plan issuers in the marketplace and Medicare Advantage plans would be excluded, and that disappointed stakeholders such as the American Hospital Association.

"The proposed rule is a welcome step toward helping clinicians spend their limited time on patient care," Ashley Thompson, senior vice president of public policy analysis and development for AHA, said in a statement. "We urge the agency to reconsider and hold Medicare Advantage plans accountable to the same standards."

The proposed rule would:

  • Cap the amount of time it takes for payers to issue decisions on prior authorizations to 72 hours for urgent requests and seven days for non-urgent ones.

  • Require payers to include a specific reason when denying a prior authorization request -- regardless of how it was submitted -- and to publicly report data about their prior authorization process. 

  • Medicaid, Children's Health Insurance Program and Qualified Health Plan payers would be required to develop a platform for payer-to-provider data sharing of claims and encounter data, with the desired outcome to allow physicians to know in advance what prior authorization paperwork they need and integrate the platform with a provider’s electronic health record so they can send and receive responses electronically.

Click here to learn more from CMS.

The New 2019 Prior Authorization Law
The Texas Department of Insurance (TDI) proposed a rule to implement Texas' new prior authorization law, SB 1742, which was passed by the 2019 Texas Legislature.

Click here to read the proposed rule, which governs health plans that are regulated by the state of Texas. (ERISA plans are regulated by the federal government.)

If you have taken the effort to view the prior authorization requirements on the health plans' websites as a result of the new law, let TOA know by replying to this e-mail. We would like to hear your feedback.

Some of the key champions who made this happen include Rep. Greg Bonnen, MD (R-Friendswood), Sen. Charles Schwertner, MD (R-Georgetown), Sen. Dawn Buckingham, MD (R-Lakeway), Rep. Julie Johnson (D-Dallas), and Sen. Jose Mendendez (D-San Antonio).

Some of the key provisions include:

(1) An HMO or a preferred provider benefit plan must make the requirements and information about the preauthorization process readily accessible to enrollees, physicians, health care providers, and the general public by posting the requirements and information on the HMO's or the preferred provider benefit plan's public internet website.

(2) The preauthorization requirements and information described by paragraph (1) of this section must:

(A) be posted: (i) conspicuously in a location on the public internet website that does not require the user to login or input personal information to view the information; except as provided by paragraph (3) or (4) of this subsection; (ii) in a format that is easily searchable; and (iii) in a format that uses design and accessibility standards defined in Section 508 of the U.S. Rehabilitation Act;

(B) except for the screening criteria under subparagraph (D)(iii) of this paragraph, be written: TITLE 28. INSURANCE Proposed Sections Part I. Texas Department of Insurance Page 31 of 36 Chapter 19. Licensing and Regulation of Insurance Professionals (i) using plain language standards, such as the Federal Plain Language Guidelines found on www.PlainLanguage.gov; and (ii) in language that aims to reach a 6th to 8th grade reading level, if the information is for enrollees and the public;

(C) include a detailed description of the preauthorization process and procedure; and

(D) include an accurate and current list of medical or health care services for which the HMO or the preferred provider benefit plan requires preauthorization that includes the following information specific to each service:
(i) the effective date of the preauthorization requirement;
(ii) a list or description of any supporting documentation that the HMO or preferred provider benefit plan requires from the physician or health care provider ordering or requesting the service to approve a request for that service;
(iii) the applicable screening criteria, which may include Current Procedural Terminology codes and International Classification of Diseases codes; and
(iv) statistics regarding the HMO's or the preferred provider benefit plan's preauthorization approval and denial rates for the service in the preceding calendar year, including statistics in the following categories:
(I) physician or health care provider type and specialty, if any;
(II) indication offered;
(III) reasons for request denial;
(IV) denials overturned on internal appeal;
(V) denials overturned by an independent review organization; and TITLE 28. INSURANCE Proposed Sections Part I. Texas Department of Insurance Page 32 of 36 Chapter 19. Licensing and Regulation of Insurance Professionals (VI) total annual preauthorization requests, approvals, and denials for the service.
6. Distribution of Third Round of HHS's Provider Relief Funds
TOA told you about HHS's latest round of provider relief funds in October. Click here in case you missed it.

The Washington, DC public affairs firm McDermott+Consulting created an update on the distribution. Click here to view it.

Also, Asbel Montes, who is an expert in the ambulance billing industry, created a useful video update on the third round and delays. Click here to view the video.
7. New Round of PPP Loans Coming
Congress' end-of-year package included a new round of PPP loans. The Small Business Administration (SBA) has 10 days to develop the rules after the legislation is signed into law.

TOA will include a summary of the rules on this web page once they are available.
8. TOA Files Amicus Brief in Texas Supreme Court Personal Injury Case
TOA filed an amicus brief in the Texas Supreme Court to oppose legal efforts to add unnecessary discovery for physicians involved in delivering medical care to patients in personal injury cases.

"TOA supports Real Parties In Interest Saint Camillus Medical Center, Andrew Indresano, MD, And Pine Creek Medical Center’s Brief on the Merits. Accordingly, TOA, which represents Texas orthopaedic surgeons, has an interest in preventing the type of discovery sought against non-party physicians, in protecting the trade secrets and proprietary and confidential information of physicians, and in preserving injured patients’ access to physicians."

Click here to view TOA's amicus brief. The Supreme Court heard the case on January 4, 2021.
9. TOA's 2021 Texas Legislature Bill Tracker
Members of the 2021 Texas Legislature started filing legislation in early November. Click here to view TOA's bill tracker, which takes a look at the musculoskeletal-related issues. It's still early; we are expecting bills of greater significance to be filed over the next few weeks.

The 87th Texas Legislature will hold its swearing-in ceremony on January 12. The Legislature typically goes into hibernation for the rest of January: The House will likely name its committee assignments in February, and then both chambers will start to hold committee hearings in the second half of February.

TOA's e-mail updates will be consumed by updates from the Texas Legislature over the next five months. The Legislature, which meets every other year, will wrap up on Memorial Day.

10. Upcoming ODG & Workers' Comp Webinars
Click here to view TDI-DWC's upcoming webinars.

ODG Training: February 4
Effective March 31, 2021, ODG Legacy will sunset in favor of the new ODG by MCG website.  ODG will hold a webinar on February 4. Click here to learn more.
Texas Orthopaedic Association www.toa.org