College of American Pathologists
Printable Version

  STATLINE — CAP’s Bi–Weekly Federal and
  State Advocacy E–Newsletter

November 25, 2009  •  Volume 25, Number 24
Next Issue: December 10, 2009
© 2009 College of American Pathologists

In This Issue:

Healthcare Reform Moves Forward in the Senate: Key Provisions Could Impact Physicians
CMS Delays Halting Payments on Claims from Ordering Physicians Not in PECOS Database
Patient Information Breach Notification Requirements: Enforcement Begins in February
CMS Reports Sharp Increase in PQRI Payments in 2008
Twenty Reasons To Be Thankful

Healthcare Reform Moves Forward in the Senate: Key Provisions Could Impact Physicians

After squeaking through with just 60 votes to invoke cloture, the Senate will take up debate on The Patient Protection and Affordable Care Act next week. If it passes with just some of the provisions it now contains, it could change healthcare in this country for a generation. While national attention is focused on its estimated cost/benefit and insurance reforms, the bill contains a number of measures that impact physicians directly.

First and foremost, it does not replace the SGR formula. Rather than follow the House’s lead to repeal the SGR and provide a permanent fix, the Senate bill calls for a one-year, .5% positive update for 2010.

It calls for half of the 5-year, 10% bonus earmarked for primary care services (and some general surgery services performed in health professional shortage areas) to be offset by reductions to all other codes. In contrast, the House bill would pay for the bonus through the Medicare trust fund.

The bill also contains several additional cost-cutting measures. First is the creation of a Medicare Advisory Board to develop and submit proposals to Congress to extend Medicare solvency, slow cost-growth, and improve quality. Board members would be appointed by the President and confirmed by the Senate. Their proposals would be aimed at meeting defined targets to reduce Medicare spending and in years when Medicare costs are projected to be unsustainable, the Board’s proposals will take effect unless Congress passes an alternative measure with the same level of savings. The Board proposals could not ration care, raise taxes or Part B premiums, or change Medicare Benefit, eligibility, or cost-sharing standards.

Next, it expands the authority of the HHS Secretary to review and adjust fee schedule rates for physician services, including bundling code payments for rates that are found to be misvalued or inaccurate. It explicitly specifies “multiple codes that are frequently billed in conduction of furnishing a single services; codes with low relative values, particularly those that are often billed multiple time for single treatment; and codes which have not been subject to review since the implementation of the RBRVS,” all which apply for many pathology physician services.

The Clinical Lab Fee Schedule would be reduced annually by 1.75% beginning in 2011 through 2015. The legislation states this can result in a reduction below 0.0%, and a rate less than the previous year. The bill also contains a new productivity adjustment to the CLFS, which cannot result in an adjustment of less than 0.0% per year. Current productivity adjustments are projected to be between 1.1 -1.4% over the next 10 years.

There are also two provisions for rewarding and penalizing physicians based on quality reporting and health outcomes. The first is a budget-neutral, value-based payment modifier to the physician fee schedule formula based on the quality of care furnished compared to cost. HHS would begin publishing quality and cost measures in 2012; it would begin rulemaking in 2013; the initial performance period for physicians would begin in 2015, and by 2017 it is anticipated that all physicians and groups of physicians would be affected.

The bill also proposes changes to the Physician Quality Reporting Initiative (PQRI). It would pay bonuses of 1% is 2011, but reduce the bonus to .5% in 2012-2014, far less than the 2% prescribed under current law. The bill goes further, imposing 1.5% penalties on physicians who do not participate in the program in 2015, and a 2% penalty in 2016. This could be an issue for pathologists and some other specialties as the process for having measures approved has been idiosyncratic.

The far-reaching bill requires new disclosures for any payment or transfer of anything of value to a physician, practice or hospital, and imposes new restrictions on physician self-referral and physician-owned hospitals. It establishes a Center of Medicare and Medicaid Innovation inside CMS to test innovative payment and service delivery models. Testing would begin in January 2011. If this provision is enacted, the Center would be the likely place within CMS to oversee a formal demonstration project to evaluate the role of pathologists in the coordinated care model.

While debate is scheduled to begin next week, it will likely take weeks to reach a conclusion, perhaps going all the way to Christmas. Senators on both sides are likely to introduce amendments, and some are likely to try to delay a vote as long as possible.

Most of the bill’s provisions were included in the bill passed by the Senate Finance Committee earlier this year. See how CAP responded in a Letter to the Senate Finance Committee in May.

Advocacy staff continues to review the bill’s legislative language and advocate on key issues. We will continue to keep CAP members informed as events unfold.

Comment On This Article

CMS Delays Halting Payments on Claims from Ordering Physicians Not in PECOS Database

Physicians and other Medicare Part B providers now have until April 5, 2010 to register in Medicare’s “Provider Enrollment, Chain, and Ownership System” (PECOS) before CMS halts payments to any provider receiving orders from a physician not in the system. The delay comes after CAP and over 50 other medical groups urged CMS not to suspend payments. The policy was scheduled to go into effect on January 5, 2010.

CMS began use of the PECOS system in November 2003. Some Medicare providers have not updated their enrollment records because the information has not changed. However, according to CMS all physicians and Part B providers must have an updated listing in PECOS. For some this may require submitting an initial enrollment application to establish a current enrollment record.

The threat of halting payment on a claim impacts all Medicare providers to whom a provider not listed in PECOS might refer, order, or supply services.

“Despite being enrolled in Medicare, if physicians and other healthcare practitioners are not in the PECOS database or in some cases contractor files, those physicians, suppliers, and other healthcare practitioners to whom they refer and order services will not be paid,” CAP and the other medical groups said.

According to CMS, the delay “will give physicians and non-physician practitioners who order items or services for Medicare beneficiaries or who refer Medicare beneficiaries to other Medicare providers or suppliers sufficient time to enroll in Medicare or take the action necessary to establish a current enrollment record in Medicare.”

Visit the CMS PECOS website to find out more about updating your PECOS listing or enrolling.

Comment On This Article

Patient Information Breach Notification Requirements: Enforcement Begins in February

Healthcare providers and other covered entities under the Health Insurance Portability and Accountability Act (HIPAA), must promptly notify patients of security breaches made by them or their business associates if the breach involves their medical information, according to regulations issued by the U.S. Department of Health and Human Services (HHS), which went into effect earlier this year. Those who do not comply by February 22, 2010 could face sanctions or financial penalties as HHS plans to increase enforcement of patient information security regulations.

If a breach is discovered, physicians are required to determine within a reasonable time period whether it poses a significant risk of financial, reputational, or other harm to the affected individual(s). If there is significant risk of harm, breach notification must be promptly provided to the affected individuals (within 60 days of the date the breach occurred), as well as the Secretary of the Department of Health and Human Services, and in cases affecting 500 or more individuals, to the media.

It should be emphasized that under the new regulation, healthcare providers are accountable for reporting breaches experienced by their business associates, and they are required to inform their patients within the 60-day window if the breach is judged to pose risk of harm.

The new rule covers the unauthorized acquisition, access, use or disclosure of unsecured patient health information (PHI) as a result of a security breach. Unsecured PHI is any patient health information that is not secured through a technology or methodology specified by HHS that renders the PHI unusable, unreadable, or indecipherable to unauthorized individuals.

In its updated Guidance to Render Unsecured Protected Health Information Unusable, Unreadable or Indecipherable to Unauthorized Individuals, HHS has specified encryption and destruction as the technologies and methodologies that render protected health information unusable, unreadable, or indecipherable to unauthorized individuals. Entities subject to the HHS regulations that secure health information as specified by the HHS guidance are not required to notify in the event of such a breach.

The rule lays out a number of very specific requirements and procedures for breach identification and notification. Read more details on the Breach Notification Rule.

Comment On This Article

CMS Reports Sharp Increase in PQRI Payments in 2008

Incentives paid to participants in the Physicians Quality Reporting Initiative (PQRI) increased nearly three-fold last year with participating physicians receiving $92 million for 2008, compared to $36 million just a year earlier. The number of professionals who earned an incentive payment for reporting quality related data to Medicare also increased from 56,700 in 2007 to 85,000 in 2008, although the percentage of participating physicians who succeeded in receiving payment remained close to 50% both years. The average incentive amount for an individual participant in 2008 was $1,000, with the largest payment to an individual totaling over $98,000.

The PQRI is a voluntary program that allows physicians and other eligible healthcare professionals to receive incentive payments for satisfactorily reporting data on quality measures related to services furnished to Medicare beneficiaries. In 2008, participants received incentive payments of 1.5% of their total estimated allowed charges under Medicare Part B for covered professional services. For successful participation in 2009, incentive payments will increase to 2.0%.

Much of the growth of the program can be attributed to the increased number of quality measures. The number of measures went from 74 in 2007 to 119 in 2008. Nearly all of them are clinical performance measures, such as the percentage of patients who received necessary mammograms and cancer screenings.

The agency added 52 new quality measures for the 2009 PQRI year (as well as removing others), raising the total number of measures to 153. Currently there are two pathology measures on breast cancer reporting and colon cancer reporting. No new pathology measures were added in 2009.

The College is working to shepherd additional measures through the lengthy review process. Nine draft pathology measures are currently open for public comment until midnight tonight.

2008 was the first year participants could report data on quality measures through one of the 31 third-party, qualified medical registries that many participants already use to report data to researchers about common care processes for diabetes, kidney disease, and preventive medicine. About 17% of the incentive payments made for 2008 were paid to those who reported through a registry.

Read the PQRI 2008 Results Fact Sheet for more information about 2008 program results and initiatives.

Read about changes in 2010 in the PQRI 2010 Fact Sheet.

Comment On This Article

Twenty Reasons To Be Thankful

Normally Statline focuses on health policies impacting pathologists. Maybe it’s the short work week, maybe it’s all the excitement whipped up by healthcare reform. Whatever it is, we thought we’d share this link recognizing the impact our medical system has had on public health and well being, from the Wall Street Journal’s Health Journal, Twenty Advances to Be Thankful For.

Happy Thanksgiving to all from the CAP Advocacy team.

Comment On This Article


202-354-7100  •  202-354-7155 (fax)  •  800-392-9994


Related Links Related Links




Customize CAP Ads with your laboratory’s logo