2020 Year-End Physician Payment and Coverage Advocacy Highlights

Dec 10, 2020

Medicare Inpatient Hospital Rule

ASH offered comments on the 2020 proposed rule for the Centers for Medicare and Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS). The rule determines payment levels and related provisions for Medicare patients who are admitted to the hospital. ASH submitted comments in July on the proposed rule. The Society is pleased that many of the provisions ASH supported have been finalized, including the creation of a new Medicare Severity Diagnosis Related Group (MS-DRG) (018) for Chimeric Antigen Receptor (CAR) T-cell Immunotherapy. CMS also finalized its proposal to account for the cost differentiation between clinical trial and non-clinical trial cases when determining payment rate for the new CAR-T MS-DRG – CMS will exclude clinical trial cases from the calculation of the weight of MS-DRG 018. ASH was also supportive of this and recognizes that it was a significant step for CMS.

Medicare Physician Fee Schedule

On December 1, the Centers for Medicare and Medicaid Services (CMS) released the Medicare Physician Fee Schedule (PFS) Final Rule outlining changes to be implemented on January 1, 2021. The rule updates payment policies and payment rates for services provided in the physician office. ASH was pleased to see that CMS finalized the changes to the office/outpatient evaluation and management (E/M) services finalized in the CY2020 rulemaking. CMS, however, did also finalize a conversion factor (CF), which is a 10.2% reduction from the 2020 CF, resulting in a payment cut to all services provided under the Medicare PFS, including those performed by hematologists and hematologists/oncologists. This was a result of the budget neutrality requirements. ASH urged CMS to waive these requirements while still moving ahead with the new Medicare office visit E/M payment policy. CMS is not extending most of the telehealth flexibilities and increased payments allowed during the COVID-19 public health emergency (PHE), but the agency did create a new audio-only code, G2252, (0.50 Work RVUs) to describe 11-20 minutes of medical discussion to determine the necessity of an in-person visit. (Note – the PHE expires on January 20, 2021; ASH expects that U.S. Department of Health and Human Services (HHS) will extend it for another ninety days).

Telehealth

This year, as a result of the COVID-19 public health emergency (PHE), ASH engaged in advocacy surrounding access to and adequate reimbursement for telehealth services, including audio-only services. Early in the COVID-19 pandemic, CMS announced coverage and payment for audio-only services, which were previously not covered. The payment, however, was very low, making it unlikely that physicians would utilize these codes and/or submit claims for reimbursement. ASH joined a number of other medical specialty societies, including the American Medical Association, to advocate for increased reimbursement for these codes. CMS responded and increased the reimbursement for the three audio-only codes most commonly used by hematologists to align the payment with the comparable in-person office visits. ASH continues to advocate for CMS to make many of the telehealth changes granted during the PHE permanent, including the coverage of and improved reimbursement for audio-only services.

AMA, CPT Coding, RUC, and Medicare Payment Policies for Hematology-Specific Services

ASH members attended the virtual AMA House of Delegate meetings in June and November of 2020. ASH now has two delegates, Dr. Chancellor Donald and Dr. Leonard Heffner, two alternate delegates, Dr. Lawrence Solberg and Dr. Kelsey Martin, as well as a delegate for the Resident and Fellow Section (RFS), Dr. Amar Kelkar. Two delegates, in addition to the RFS delegate, can attend each meeting, and vote on resolutions, which help to shape AMA policy positions.

The American Medical Association (AMA) recently announced that it has taken action to explicitly recognize racism as a public health threat and have detailed a plan to mitigate its effects. This new policy is a result of resolutions voted on during the November AMA Interim Meeting of the House of Delegates (HOD). ASH’s AMA delegates participated in this meeting and supported these resolutions. ASH staff is currently working with members to create a policy statement on Addressing Diversity, Equity, and Inclusion in Hematology Practice and Research.

Medicare Contractor Advisory Committee Meeting

This year ASH hosted two virtual Carrier Advisory Committee (CAC) Network Meetings. This was the first year ASH hosted this meeting without the American Society of Clinical Oncology (ASCO) and because the meetings were virtual, it allowed time for two meetings. The June meeting focused on the changes to the CAC and the local coverage determination (LCD) process as well as an update on ASH’s clinical practice guidelines, with an emphasis on how evidence used to develop ASH’s guideline recommendations can help to inform LCDs. The October meeting highlighted two clinical topics – 1) Next Generation Sequencing and 2) Coverage for Stem Cell Transplantation for Patients with Lymphoma. ASH is currently working with ASH members and Medicare Administrative Contractor (MAC) Medical Directors on the latter topic to help ensure that stem cell transplantation for patients with lymphoma is covered and accessible regardless of where one lives in the country.

Sickle Cell Disease

ASH continues to work on a number of advocacy issues related to payment for and coverage of therapies and treatments used for sickle cell disease (SCD).

  • On April 2, ASH submitted comments in response to the proposed rule outlining changes to Medicare Part D and Medicare Advantage for calendar year 2021. Specifically, the Society commented on two provisions related to individuals with SCD—supporting the proposal that individuals with SCD be excluded from drug management programs and from the new definition of “inappropriate prescribing of opioids” included in the proposed rule.
  • On July 17, ASH submitted a letter to CMS in support of a proposed rule aiming to reduce barriers within the Medicaid program that would make it easier for payers to implement value-based payment (VBP) arrangements. The rule also included proposals that could potentially limit opioid prescriptions; ASH urged the agency to exempt individuals with SCD from these restrictions.
  • ASH staff met with ADM Brett P. Giroir, MD, HHS Assistant Secretary for Health, to discuss utilization management techniques, such as step therapy and prior authorization, and how they have impacted access to many therapies and treatments used for SCD. ASH continues to explore ways through which CMS could help to mitigate some of these effects and ensure individuals living with SCD have access to the therapies and treatments they need, when they need them.