/ en Mon, 28 Apr 2025 04:59:12 -0500 Wed, 02 Aug 23 14:46:15 -0500 <div class="container"> <div class="row"> <div class="col-md-8"> <p>The Centers for Medicare & Medicaid Services (CMS) July 13 issued its physician fee schedule <a href="https://public-inspection.federalregister.gov/2023-14624.pdf" target="_blank">proposed rule</a> for calendar year (CY) 2024. The rule also includes proposals related to the Medicare Shared Savings Program (MSSP) and the Quality Payment Program (QPP), both of which were created by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Comments on the proposed rule are due to CMS by Sept. 11. The final rule will be published on or around Nov. 1, and policies would generally take effect Jan. 1, 2024.</p> <div class="panel module-typeC"> <div class="panel-heading"> <h3>Key Highlights</h3> <p>CMS’ proposed policies would:</p> <ul> <li>Reduce the PFS conversion factor by 3.34% to $32.75, as compared to $33.89 in CY 2023</li> <li>Delay for at least one year implementation of a policy that would define the substantive portion of a split (or shared) visit based on the amount of time spent by the billing practitioner</li> <li>Delay implementation of the rebased and revised Medicare Economic Index (MEI) until future rulemaking</li> <li>Extend several telehealth waivers through 2024, which were outlined in the Consolidated Appropriations Act (CAA) of 2023; as well as regulatory waivers for virtual supervision and billing for virtual therapy services</li> <li>Revise the data reporting period and phase-in of payment reductions for clinical laboratory tests under the Clinical Laboratory Fee Schedule (CLFS)</li> <li>Pause the Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging program indefinitely in order to conduct further evaluation</li> <li>Permit the reporting of Medicare-only clinical quality measures in the MSSP</li> <li>Add five new Merit-Based Incentive Payment System (MIPS) Value Pathways for CY 2023</li> <li>Increase the MIPS performance threshold for achieving positive payment adjustments</li> <li>Offer Advanced Alternative Payment Model (APM) track bonus payments in 2025 to those that qualify</li> </ul> </div> </div> <h2>AHA TAKE</h2> <p>The AHA is concerned with CMS’ proposed payment update, which would substantially reduce CY 2024 payments from their CY 2023 levels. This update would pose significant risks to patients’ access to care and health systems’ financial stability, particularly for safety-net providers. Our concern is heightened by the fact that this cut is coming in the wake of over three years of unrelenting financial pressures on the health care system due to COVID-19, along with rising inflation, increasing input costs, and persisting staffing shortages and supply chain disruptions.</p> <p>However, we are pleased that CMS is proposing to delay implementation of its split/shared visit policy and revised MEI, which would have resulted in significant reductions and redistributions in physician revenue on top of this proposed rule’s other cuts. We are also encouraged by the proposed reevaluation of the Appropriate Use Criteria for Advanced Diagnostic Imaging program. We have expressed longstanding concerns that the current program could result in inappropriate claims denials, increased administrative burden and ultimately unnecessary delays in patient care.</p> <p>Finally, we thank CMS for proposing to extend through 2024 many of the COVID-19 telehealth flexibilities. In addition, the AHA continues to encourage CMS to work with Congress on permanent adoption of waiver provisions such as eliminating the originating and geographic site restrictions for all telehealth services and expanding telehealth eligibility to certain practitioners. We also encourage CMS to leverage statutory authority to make permanent certain waivers through regulation.</p> <h2>WHAT YOU CAN DO</h2> <ul> <li><strong>Share</strong> this advisory with your chief medical officer, chief financial officer and other members of your senior management team, as well as key physician leaders and nurse managers.</li> <li><strong>Register <a href="https://aha.adobeconnect.com/eqh0x35e8ws5/event/registration.html" target="_blank">here</a></strong> to participate in AHA’s member-only webinar on Wednesday, Aug. 23 at 4 p.m. ET to discuss the proposed rule.</li> <li><strong>Assess</strong> the potential impact of the proposed payment and quality changes on your Medicare revenue and operations.</li> <li><strong>Submit comments to CMS with your specific concerns by Sept. 11 at <a href="http://www.regulations.gov/" target="_blank">www.regulations.gov</a>.</strong></li> </ul> <h3>View the detailed Regulatory Advisory below.</h3> </div> <div class="col-md-4"> <p><a href="/system/files/media/file/2023/08/medicare-physician-fee-schedule-proposed-rule-for-cy-2024-advisory-8-2-23.pdf" target="_blank"><img alt="Cover Medicare Physician Fee Schedule Proposed Rule for CY 2024 Advisory" data-entity-type="file" data-entity-uuid="78ba80f3-efb8-4331-9219-87dad779124a" src="/sites/default/files/inline-images/cover-medicare-physician-fee-schedule-proposed-rule-for-cy-2024-advisory-8-2-23.png" width="510" height="659"></a></p> </div> </div> </div> Wed, 02 Aug 2023 14:46:15 -0500 Appropriate Use /news/headline/2022-07-07-cms-delays-enforcement-appropriate-use-criteria-advanced-imaging <p>The Centers for Medicare & Medicaid Services today announced that it will delay indefinitely the payment penalty period of the Appropriate Use Criteria program for advanced imaging services. The program, which was set to potentially go into effect on Jan. 1, 2023, requires imaging provider claims to include additional information regarding the ordering physician’s consultation with clinical decision support tools. The AHA since 2021, through letters to CMS dating back to last <a href="/lettercomment/2021-06-21-aha-ama-urge-cms-delay-advanced-imaging-appropriate-use-timeline?utm_source=newsletter&utm_medium=email&utm_campaign=aha-today&mkt_tok=NzEwLVpMTC02NTEAAAGFeiv8QeioZnQhGPdgSAcYMD9w5DsQKO7Zq2zCM6KV6ccLKu8E2gjk94UHjEHs9z2IOYaLyKkAlOTBKtLEKZzXXjOxmswFCvN6vGfm3yCmPHtj">June</a> and <a href="/system/files/media/file/2021/09/aha-comments-on-cms-proposed-pfs-rule-9-13-21.pdf?utm_source=newsletter&utm_medium=email&utm_campaign=aha-today&mkt_tok=NzEwLVpMTC02NTEAAAGFeiv8Qd7AMuHRH6hctUcZ-kCl4AtpLGIrcjOhV75DRvWFXg5bLGvtdTOK-Pwt7M3oaLmvjeB1csU3QosUgjCZOBG4ULYPjifHjg2hZnhQ06PU">September</a>, has led a sustained effort to urge delayed enforcement of these provisions until the process can occur efficiently without adding significant administrative burden on providers.</p> Thu, 07 Jul 2022 15:57:00 -0500 Appropriate Use /special-bulletin/2022-03-09-house-appropriations-committee-unveils-omnibus-spending-package-health <div class="container"> <div class="row"> <div class="col-md-8"> <p>The House Appropriations Committee announced an agreement on omnibus appropriations legislation funding the federal government through the end of the current fiscal year. The legislation also includes provisions beneficial to hospitals and health systems.</p> <p>The omnibus spending bill, with Ukraine emergency spending attached, has been combined into one package, and <a href="https://rules.house.gov/sites/democrats.rules.house.gov/files/BILLS-117HR2471SA-RCP-117-35.pdf" target="_blank">legislative language</a> and a <a href="https://appropriations.house.gov/sites/democrats.appropriations.house.gov/files/Appropriations%20Division-by-Division%20Summary.pdf" target="_blank">summary</a> were released early this morning. <strong>House Democrats this afternoon pulled all COVID-19 relief that was going to be attached to the bill as some lawmakers expressed concerns about spending offsets for the additional COVID-19 relief funding supplemental package.</strong></p> <p>The House is expected to vote on the revised omnibus spending bill today. In addition, the House today is expected to approve a short-term continuing resolution funding the government. The Senate could try to clear the omnibus package by the weekend, but final passage may not come until next week. The Senate also is likely to clear a continuing resolution before current funding for the government expires at 11:59 p.m. ET on March 11. Watch for more details from the AHA.</p> <h2>AHA Take</h2> <p>We appreciate that Congress included important provisions in the legislative package related to telehealth, 340B and maternal health that will help hospitals and health systems enhance the health of their patients and communities. However, we are disappointed that Congress did not provide additional COVID-19 relief. We will continue to urge Congress to provide additional support to hospitals and health systems and their front-line caregivers as we enter year three of the COVID-19 public health emergency.</p> <p><strong>Based on an initial review of the legislation, the following are highlights of provisions that affect hospitals and health systems.</strong></p> <h2>Telehealth Service Extensions</h2> <p>The legislation includes provisions to extend and expand telehealth flexibilities for 151 days after the end of the COVID-19 public health emergency. These include:</p> <ul> <li>Expanding originating site to include any site at which the patient is located, including the patient’s home;</li> <li>Expanding eligible practitioners to furnish telehealth services to include occupational therapist, physical therapist, speech-language pathologist and audiologist;</li> <li>Extending the ability for federally qualified health centers (FQHCs) and rural health clinics (RHCs) to furnish telehealth services;</li> <li>Delaying the 6-month in-person requirement for mental health services furnished through telehealth until 152 days after the emergency, including the in-person requirements for FQHCs and RHCs;</li> <li>Extending coverage and payment for audio-only telehealth services;</li> <li>Extending the ability to use telehealth services to meet the face-to-face recertification requirement for hospice care; and</li> <li>Requiring the Medicare Payment Advisory Commission to conduct a study on the expansion of telehealth services and to require the Department of Health and Human Services (HHS) Secretary to publicly post data with respect to telemedicine utilization.</li> </ul> <h2>Cybersecurity</h2> <p>The legislation would require critical infrastructure sectors, including hospitals and health systems, to report cyber incidents within 72 hours and any ransomware payments made within 24 hours to the Cybersecurity and Infrastructure Security Agency at the Department of Homeland Security. Currently, hospitals and health systems are required to report cyber breaches affecting more than 500 people to the Office of Civil Rights at HHS “without unreasonable delay” and “no later than 60 calendar days from the breach.” More time is provided for reporting incidents affecting less than 500 people. The legislation would allow for some exemptions for certain entities that already report similar information on a similar timeline.</p> <h2>Maternal Health</h2> <p>The legislation includes several important provisions to improve maternal health outcomes.</p> <h3>Maternal Health Quality Improvement</h3> <p>The legislation would provide for Public Health Service Act grants to develop and disseminate best practices with authorization of $45 million for 2023-2027; accredit health professional schools to train health care professionals about perceptions and biases with authorization of $15 million for 2023-2027; support states and tribal organizations for integrated health care services with authorization of $50 million for 2023-2027; and instruct HHS to include pregnant and postpartum women as part of their public awareness campaign.</p> <h3>Improving Rural Maternal and Obstetric Care Data</h3> <p>This provision would amend the Public Health Service Act to improve rural maternal and obstetric care data collection and care networks with authorization of $15 million for 2023-2027, as well as establishes grants to support health care professional training and telehealth resources with authorization of $25 million for 2023-2027.</p> <h2>Medicaid Provisions</h2> <p>The legislation includes two Medicaid provisions.</p> <h3>Extended Increased FMAP for Territories</h3> <p>This provision would extend the increased Federal Medical Assistance Percentage (FMAP) for the five U.S. territories through Dec. 13, 2022. Historically, the territories FMAP was 55%. This provision would maintain Puerto Rico’s increased FMAP at 76%, and maintain increased FMAP for the Virgin Islands, Guam, Northern Mariana Islands and American Samoa at 86%. The section also would increase Puerto Rico’s federal allotment by $200 million for fiscal year (FY) 2022.</p> <h3>Increasing State Flexibility with Respect to Third Party Liability</h3> <p>This provision would provide state Medicaid programs with an enforcement mechanism to address third party liability for care provided to a Medicaid beneficiary. A large proportion of Medicaid beneficiaries have third party sources of insurance coverage and for these beneficiaries the third party source of coverage must pay for care provided before the Medicaid program will pay. This provision strengthens the Medicaid program enforcement to seek recovery for issued Medicaid payments. In addition, this provision applies to all potential denials on the part of commercial plans, including prior authorization denials, by not allowing commercial health plans to avoid payment by saying that the service failed prior authorization if the state had waived prior authorization for the same service.</p> <h2>340B Eligibility Exceptions due to COVID-19 Public Health Emergency</h2> <p>The legislation would protect certain 340B hospitals that lost their 340B eligibility due to a drop in their disproportionate share hospitals (DSH) adjustment percentage below the required threshold for 340B eligibility to gain limited access to the program. Access to the 340B drug discounts would be available only from the date of the bill’s enactment through the end of 2022 and not retrospectively. This exception would apply only to 340B hospitals actively participating in the 340B program from the day prior to the start of the COVID-19 public health emergency (Jan. 31, 2020) and who subsequently lost eligibility during the cost reporting periods of 2020, 2021, and ending Dec. 31, 2022. Hospitals qualifying for the exception would be required to attest to the HHS Secretary that the reason for their loss of 340B eligibility was the result of “any actions taken by or other impact on such hospital in response to or as a result of the COVID-19 public health emergency that may have impacted the ability to meet the applicable requirement for the disproportionate share adjustment percentage.”</p> <h2>Health Care Appropriations</h2> <p>The omnibus appropriations bill would provide $1.5 trillion in discretionary spending for FY 2022. The package would fund various health-related agencies at the following levels, many of which reflect new investments in areas of interest for hospitals and health systems:</p> <ul> <li><strong>HHS</strong>: $108.3 billion in total spending, an increase of $11.3 billion. As part of this appropriation, Congress would establish and/or fund the following agencies, among others: <ul> <li><strong>Centers for Medicare & Medicaid Services</strong>: $4 billion in total spending, an increase of $50 million.</li> <li><strong>Advanced Research Projects Agency for Health (ARPA-H)</strong>: $1 billion to establish ARPA-H with the intent of accelerating the development of scientific breakthroughs for diseases such as ALS, Alzheimer’s disease, diabetes and cancer.</li> <li><strong>National Institutes of Health</strong>: $45 billion, an increase of $2.25 billion with a particular focus on investments in research to address cancer, HIV and dementia, among other conditions.</li> <li><strong>Centers for Disease Control and Prevention:</strong> $8.5 billion, an increase of $582 million, with a particular emphasis on improving the nation’s public health infrastructure, including data collection and monitoring.</li> <li><strong>Substance Abuse and Mental Health Services Administration</strong>: $6.5 billion, an increase of $530 million to invest in a number of mental health programs, including those particularly targeted at children and youth.</li> <li><strong>Health Resources and Services Administration</strong>: $8.9 billion, an increase of $1.4 billion, to improve access to care in underserved communities, develop the workforce, and improve maternal and child health outcomes.</li> </ul> </li> </ul> <p>Separately, the legislation also would increase funding for the Food and Drug Administration (FDA) and the Federal Emergency Management Agency (FEMA):</p> <ul> <li><strong>FDA</strong>: $3.3 billion, representing an increase of $102 million with new investments to address the opioid crisis, improve medical supply chain surveillance, facilitate the development of treatments for rare cancers and accelerate medical product development as authorized in the 21st Century Cures Act.</li> <li><strong>FEMA</strong>: $23.9 billion, representing an increase of $2.19 billion with a particular focus on disaster response and recovery efforts.</li> </ul> <h2>Further Questions</h2> <p>If you have further questions, please contact AHA at 800-424-4301.</p> </div> <div class="col-md-4"> <p class="text-align-center"><strong><a class="btn btn-primary btn-wide" href="/system/files/media/file/2022/03/house-appropriations-committee-unveils-omnibus-spending-package-with-health-provisions-bulletin-3-9-22.pdf">Download the PDF</a></strong><br />  </p> <p><a href="/system/files/media/file/2022/03/house-appropriations-committee-unveils-omnibus-spending-package-with-health-provisions-bulletin-3-9-22.pdf" target="_blank"><img src="/sites/default/files/2022-03/image-house-appropriations-committee-unveils-omnibus-spending-package-with-health-provisions-bulletin-3-9-22.png" /></a></p> </div> </div> </div> Wed, 09 Mar 2022 14:48:53 -0600 Appropriate Use /news/headline/2021-06-28-cms-urged-delay-advanced-imaging-appropriate-use-timeline <p>The AHA and American Medical Association last week urged the Centers for Medicare & Medicaid Services to delay until at least Jan. 1, 2023, the deadline for physicians, hospitals and health systems to implement appropriate use criteria for advanced diagnostic imaging services, citing “the unprecedented financial strain placed on providers by the COVID-19 public health emergency, continued technological challenges, and the need for additional programmatic guidance.”</p> <p>While CMS previously delayed the Jan. 1, 2020, start date for the program’s consultation and reporting requirements to Jan. 1, 2021, and the testing period until Jan. 1, 2022, the program “requires a significant investment in information technology systems’ changes, maintenance, workflow reconfiguration, staff training, and other resources in order for providers to comply with programmatic requirements,” the organizations <a href="/lettercomment/2021-06-21-aha-ama-urge-cms-delay-advanced-imaging-appropriate-use-timeline">wrote</a>. “The ongoing demands of meeting patient care needs caused by the pandemic leave providers unprepared and ill-equipped to devote these necessary resources to ensure a successful implementation of the AUC program under the current timeline.”</p> Mon, 28 Jun 2021 16:01:43 -0500 Appropriate Use /lettercomment/2021-06-21-aha-ama-urge-cms-delay-advanced-imaging-appropriate-use-timeline <p>Due to the unprecedented financial strain placed on providers by the COVID-19 public health emergency, continued technological challenges, and the need for additional programmatic guidance, the AHA and the American Medical Association urge CMS to delay the Jan. 1, 2022 AUC implementation date by at least one year to allow providers the opportunity to implement and test operational changes and acquire the education necessary to achieve compliance with the program. </p> Mon, 21 Jun 2021 13:32:16 -0500 Appropriate Use /lettercomment/2020-07-09-aha-ama-cms-re-implementation-appropriate-use-criteria-advanced-diagnostic <p>On behalf of our member physicians, nurses, hospitals and health systems, the ���������� Association (AHA) and the American Medical Association (AMA) are contacting the Centers for Medicare & Medicaid Services (CMS) regarding <span>the implementation of the appropriate use criteria (AUC) for advanced diagnostic imaging services mandated under the Protecting Access to Medicare Act of 2014 (PAMA). Due to the reduction in imaging services and the technological and financial strain placed on providers by the COVID-19 public health emergency, we urge CMS to delay the January 1, 2021, AUC implementation date by at least one year to allow providers the opportunity to implement and test operational changes and acquire the education necessary to achieve compliance with the program.</span></p> Thu, 09 Jul 2020 12:33:28 -0500 Appropriate Use /insights-and-analysis/2019-12-05-voices-value-conversation-reshma-gupta-md <p><span><span><span lang="EN"><span><span>In this Voices on Value piece, </span></span></span><span><span>Priya Bathija, vice president of AHA’s The Value Initiative, talks with Reshma Gupta, M.D., evaluation and outreach director of Costs of Care, about the organization’s efforts to raise awareness of the unintended financial harm of care and to disseminate innovations that reduce unnecessary costs. </span></span></span></span></p> <p><span><span><span><span>Dr. Gupta also discusses how Costs of Care programming targets clinicians, educators, health system leaders and patients separately. </span></span></span></span></p> Thu, 05 Dec 2019 11:05:38 -0600 Appropriate Use /case-studies/2019-11-08-value-initiative-members-action-inova-health-system-falls-church-va <p class="MsoNormal"><b>Inova Health System – Falls Church, Va.</b><br /> <i>Focus on High-Value Care Improves Outcomes and Value</i></p> <p class="MsoNormal">Inova Health System is involved in an interdisciplinary effort to create value by reducing services that provide little or no clinical value to patients. By standardizing pre-surgical testing processes, there is less confusion for patients and caregivers as to what tests are needed, reduced surgery delays and fewer procedure cancellations. <a href="/system/files/media/file/2019/11/value-initiative-members-in-action-inova-health-system-falls-church-va.pdf">Learn more</a>. </p> <p><a class="btn btn-default btn-round" href="/advancing-health-podcast/2019-10-23-reducing-low-value-care" target="_blank">Listen to the podcast.</a></p> Fri, 08 Nov 2019 09:35:12 -0600 Appropriate Use /case-studies/2019-06-18-value-initiative-members-action-northwestern-medicine-chicago-ill <p><strong>Northwestern Medicine — Chicago, Ill.<br /> Using the EHR to Drive Value</strong></p> <p class="MsoNormal"><span>Northwestern Medicine created multi-disciplinary teams to maximize the EHR’s capabilities and improve care across the system. These Health System Clinical Collaboratives have resulted in systemwide improvements related to the patient experience, patient safety and the clinical experience, such as fewer duplicate tests, a universal consent form and improved hand-off tools.</span></p> <p> </p> <p> </p> Tue, 18 Jun 2019 12:36:09 -0500 Appropriate Use /case-studies/2019-04-26-value-initiative-members-action-johns-hopkins-health-system-baltimore-md <p><strong>Johns Hopkins Health System – Baltimore, Md.<br /> <em>Implementing Evidence-based Practice Improves Care, Reduces Cost</em></strong></p> <p>The Johns Hopkins Health System High Value Care Committee focuses on improving patient care quality, safety and affordability by reducing practices that provide little or no value to patients. To achieve this, the health system ensures the appropriateness of its tests, procedures, treatments and medications.</p> Fri, 26 Apr 2019 12:26:14 -0500 Appropriate Use