MGMA 2021 mid-year policy update for medical groups

With half of 2021 behind us and a new Congress and Administration in full swing, MGMA continues to represent the interests of medical groups on numerous regulatory and legislative issues. We are committed to providing members with timely updates around federal policies and programs affecting their businesses and patients.

As a mid-year check-in, here is an update on the key issues we are following in Washington, D.C.:

1. Telehealth remains a top priority for medical practices and Congress

The COVID-19 pandemic highlighted the potential benefits of virtual care, but the question of reform remains. This year, Congress held several hearings with telehealth experts to explore which flexibilities should remain in place once the COVID-19 public health emergency (PHE) ends. Congressional members clearly value the role that telehealth played in delivering care throughout the pandemic, and there is a consensus that telemedicine should remain an option for Americans who want it, when appropriate. However, there are also concerns regarding fraud and overutilization. MGMA is advocating for payment parity with in-person visits, elimination of geographic and originating site restrictions, permanent coverage of audio-only visits, and continuity of care between providers and patients.¹ In the coming months, we believe that Congress will continue to debate which COVID-19 PHE flexibilities should remain. It is likely that year-end legislation will include provisions that would expand these flexibilities, such as waiving the geographic and originating site restrictions, for at least a period of time to collect data on cost and quality of care. 

2. Potential cuts to Medicare reimbursement loom as 2022 approaches

Sequester

For almost a decade, medical groups have experienced 2% across-the-board cuts to all Medicare payments. Through the CARES Act, passed in March 2020, Congress suspended the 2% cuts through Dec. 31, 2020. After advocacy from MGMA and the provider community, Congress passed legislation to continue the 2% sequester moratorium through the end of this year.2 It is possible that Congress will extend this moratorium while the PHE is in effect, but it is unlikely to remain indefinitely.

Statutory PAYGO

The Statutory Pay-As-You-Go-Act of 2010 (Statutory PAYGO) requires that spending not increase the federal budget deficit over a specific period. If legislation is enacted without certain offsets, certain across-the-board reductions are triggered. The $1.9 trillion American Rescue Plan Act of 2021, passed in March, could cause a 4% reduction in Medicare spending if not offset. Historically, a PAYGO sequester has never been triggered because Congress has always acted to waive the reductions before the cuts could go into effect. MGMA will urge Congress to act to prevent a Statutory PAYGO sequester before the end of this congressional session.

Physician Fee Schedule (PFS) conversion factor

Last year, the Centers for Medicare & Medicaid Services (CMS) finalized a conversion factor for CY 2021 in the Medicare physician fee schedule (PFS) that represented a 10% decrease from the previous year. This dramatic drop was due in part to RVU and payment increases related to office/outpatient E/M services and other payment policies. Due to MGMA advocacy, Congress acted to mitigate these cuts to reimbursement by injecting $3 billion into the PFS and delaying the implementation of the complexity add-on code (HCPCS G2211) for three years in year-end legislation. Since the $3 billion was only allocated for CY 2021, we expect to see a lower conversion factor in the proposed PFS than the one finalized after year-end legislation. MGMA is engaging with Congress to find ways to mitigate these cuts before CY 2022.3

3. Reintroduction of key piece of legislation addresses rising prior authorization burden

Prior authorization requirements are on the rise, with 81% of MGMA members reporting they have increased since 2020.4 In May, the House of Representatives reintroduced the Improving Seniors’ Timely Access to Care Act, a bill that MGMA helped draft that would streamline and standardize the way Medicare Advantage (MA) plans use prior authorization.5 MGMA will work with Congress to pass this legislation, so we can begin to see meaningful prior authorization reform. Additionally, MGMA is asking CMS to include MA plans in the scope of the CMS Interoperability and Prior Authorization Rule.6 By leaving those plans out, CMS is virtually guaranteeing that industry implementation of these automated solutions will be limited and do little to alleviate the current level of administrative burden on physician practices.

4. New surprise billing regulations forthcoming

In December 2020, the No Surprises Act was signed into law as part of the Consolidated Appropriations Act of 2021.7 With most sections of the legislation set to go into effect on Jan. 1, 2022, the Departments of Health & Human Services (HHS), Treasury and Labor must issue most regulations by Jan 1, 2022. The law was designed to protect patients against surprise medical bills and increase transparency. Broadly, for services provided by a nonparticipating provider at a participating facility or nonparticipating emergency facility, providers may not bill beyond the allowed cost-sharing amount. The plan must make an initial payment to the provider or provide a notice of denial within 30 days of the provider transmitting the bill to the plan. If the provider is not satisfied with the payment amount, they have 30 days to negotiate. If an agreement cannot be reached during that period, the Independent Dispute Resolution (IDR) process begins, in which an IDR entity selects one of the offers submitted after considering certain factors. Once guidance is issued, MGMA will educate members on what will be expected of them regarding the new law.

5. New Administration, new priorities in value-based care

Every new Administration brings with it new ideas and approaches to policy, regardless of the specific department or agency. New leadership at CMS and the CMS Innovation Center (CMMI) is bringing a fresh perspective on value-based care arrangements and alternative payment models (APMs). Since beginning her role as the new CMMI director, Elizabeth Fowler has publicly discussed her commitment to value-based care initiatives and prioritizing the success of CMMI’s existing models. She has also emphasized her desire to strengthen and prioritize advanced primary care models; to expand CMMI’s reach into Medicaid to improve multi-payer alignment within APMs; to speed along the transition to value-based care through more mandatory models; and to build a new health equity approach throughout all CMMI models (e.g., creation of new social determinants of health quality measures).

The Biden Administration’s commitment to advancing value-based care and risk-based contracting is evident in looking at the President’s Fiscal Year 2022 Budget, which calls the new Global and Professional Direct Contracting Model a “priority initiative.”8 While the model is not accepting new applicants for its 2022 cohort, it is being looked at closely within CMMI to ensure the model’s design aligns with the Administration’s broader priorities. As the Administration takes a fine-toothed comb to its existing APMs and assesses plans, MGMA has provided key recommendations to CMMI to improve the design and implementation of APMs, to provide upfront funding to model participants, and to ensure physician involvement in the development of new APMs.9

6. Health information sharing and access requirements enter uncharted waters

With regulations implementing the 21st Century Cures Act from CMS and the Office of the National Coordinator for Health Information Technology (ONC) coming into play this year, medical groups have been tasked with adopting significant workflow and process changes to comply with these new federal requirements. ONC’s information blocking requirements, which went into effect April 5, generally prohibit providers from interfering with, preventing or materially discouraging access, exchange and use of electronic health information (EHI).10 The rule also establishes eight permitted exceptions that involve not fulfilling requests or establishing alternate procedures for fulfilling requests for access, exchange or use of EHI. While compliance with these requirements is expected, there is still not a rule establishing penalties or other disincentives for providers found to be information blockers.

At the same time, the Administration is considering public feedback on a proposed rule that would make significant changes to the HIPAA Privacy Rule and patients’ access to their protected health information (PHI).11 The rule proposes to remove regulatory barriers to care coordination and case management while also creating new patient access rights. In written comments to HHS, MGMA cautioned against proposals that could compromise the security and privacy of PHI and place additional administrative burdens on medical groups at a time when they are already focused on complying with the finalized information blocking requirements.12 Given this proposed rule was issued by the previous Administration, the likelihood that its provisions will be finalized and timeline for publication of a final rule remain unclear. MGMA continues to monitor for updates from HHS.

Learn more

• For the latest updates on federal health policy, please sign up to receive the Washington Connection newsletter at mgma.com/wc.
• To get involved in #MGMAAdvocacy, you can send a template letter to your congressional representatives using our portal at mgma.com/ContactCongress.

Notes:

1. “MGMA statement on the Subcommittee on Health of the Committee on Energy and Commerce’s hearing on the future of telehealth.” MGMA. March 2, 2021.
2. “MGMA statement on Medicare sequester cuts.” MGMA. March 16, 2021.
3. “MGMA and other leading healthcare organizations urge Congress to address FY 2022 Medicare cuts in infrastructure package.” MGMA. April 27, 2021.
4. “New MGMA Poll Shows Prior Authorization on the Rise Despite COVID-19 Pandemic.” MGMA. May 20, 2021.
5. “DelBene, Kelly, Bera, Bucshon Introduce Bipartisan Legislation to Make Care More Efficient for Seniors by Reforming Prior Authorization.” The Office of U.S. Congresswoman Suzan DelBene. May 13, 2021. Available from: bit.ly/2T8Ct5n.
6. “MGMA welcomes new CMS Administrator Chiquita Brooks-LaSure.” MGMA. May 27, 2021.
7. “Text - H.R.3630 - 116th Congress (2019-2020): No Surprises Act.” Congress.gov, Library of Congress, July 11, 2019. Available from: bit.ly/3v0o4W3.
8. HHS. “Fiscal Year 2022 Budget in Brief.” Available from: bit.ly/34U81OS.
9. “MGMA and other leading healthcare organizations offer recommendations to new CMMI Director to improve APMs.” MGMA. May 26, 2021.
10. HHS. “21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program.” Federal Register. May 1, 2020. Available from: bit.ly/34XiQ2U.
11. HHS. “Proposed Modifications to the HIPAA Privacy Rule to Support, and Remove Barriers to, Coordinated Care and Individual Engagement.” Federal Register. Jan. 21, 2021. Available from: bit.ly/3zaSubd.
12. “MGMA submits comments in response to proposed modifications to HIPAA Privacy Rule.” MGMA. May 4, 2021.