Dec 30, 2011

TDI Suspends PPO Rules

The Texas Department of Insurance (TDI) suspended preferred provider benefit regulations until it adopts rules implementing legislation passed in the 2011 session of the legislature. A bulletin from Insurance Commissioner Eleanor Kitzman said the legislature passed bills that significantly affect TDI's ability to regulate health care plans.


The rules that TDI suspended were the result of work by the TDI Network Adequacy Workgroup, which included facility-based physician members. The rules are the result of four years of work, beginning with the passage of Senate Bill 1731 in 2007, the study of network adequacy issues (as required by that bill), and the passage of House Bill 2256 in 2009. Since HB 2256 passed, TDI staff have worked with health plans, hospitals, and provider stakeholders to refine the rules, which were improved through the course of two informal and one formal postings, two public stakeholder meetings, and a public hearing.

Dec 29, 2011

ICD-10: TMA Can Help Smooth the Way

Would you rather leap from ICD-9 to ICD-10 – and risk a hard fall (that might be ICD-10 code W15.XXXA: Fall from cliff, initial encounter) – or cross over via a smooth bridge?

The distance between ICD-9's 14,000 codes and ICD-10's 68,000 is long. It may well take from now until the scheduled Oct. 1, 2013, ICD-10 adoption deadline for you and your staff to learn your way around the new coding system. That's why in early 2012, TMA will begin offering these ICD-10 training opportunities for you and your staff:

  • Hands-on ICD-10 Coding Workshops. The challenge of learning a new code set can be intimidating, and for some physicians and staff it can be paralyzing. Become familiar with the ICD-10 conventions and learn to navigate the new system in an interactive workshop. Participants will gain hands-on experience by coding services using sample medical record documentation and the ICD-10 coding system. By building a solid ICD-10 foundation and understanding the rules involved, your practice can avoid decreased revenue and reduce financial liability.
  • ICD-10 Documentation Requirements (a physician-only program). Even if your practice is fully prepared, if physician documentation has not evolved, you’ll never achieve accurate coding and proper payment. Attendees will learn about the new conventions and how to modify medical record documentation techniques to support the ICD-10 coding system. Avoiding a decrease in revenue and reducing financial liability begin with the physician.
  • Private ICD-10 Training. TMA Practice Consulting can provide customized ICD-10 training for physicians and staff within the comfort of your own practice. This training is ideal for both small and large practices that prefer to have one-on-one instruction in a more intimate setting with a less rigid format. For more information or to request a proposal, email TMA Practice Consulting.

TMA is working with the American Medical Association and other state associations to stop the Centers for Medicare & Medicaid Services from implementing ICD-10 because of its burden on physician practices. But if the government doesn't listen, TMA can help you prepare. Stay abreast of TMA's ICD-10 educational programs by emailing Heather Bettridge. Let her know you want special notification of TMA's upcoming ICD-10 workshops, seminars, and webinars as details become available. Find more information on the TMA website.

Keep track of ICD-10 deadlines and other looming compliance dates with TMA's Calendar of Doom. Be prepared; be very prepared.

Dec 28, 2011

Major Insurers Still Accept 4010 Claims

Three major insurers now say they still accept and pay physicians' claims in both the HIPAA 4010 and 5010 formats through April 1, even though Jan. 1 was the deadline for physicians to begin using the 5010 claims standards. They are Medicare, Texas Medicaid, and Blue Cross and Blue Shield of Texas. UnitedHealthcare said it will accept claims in both version but did not say for how long.


As this report was prepared, the Humana, and CIGNA websites said the companies would not accept 4010 claims after Jan. 1. Genevieve Davis, director of TMA's Payment Advocacy Department, suggests physicians monitor the 5010 pages on the insurers' websites. Aetna said it would accept 4010 claims from vendors or clearinghouses, not directly from physicians. She says Aetna's position emphasizes that physicians who have not made sure their vendors have submitted a contingency plan to the insurers should do so immediately.


The Centers for Medicare & Medicaid Services said earlier this month it would delay enforcement of the new standards until April 1 to give physicians and payers more time to complete the conversion. The private insurers then followed suit.


For more information about the conversion to 5010, visit the TMA HIPAA 5010 Resource Center on the TMA website.

Dec 6, 2011

Dialogue: How to Save Grandma from the Big, Bad SGR?

U.S. Rep. Michael Burgess, MD (R-Lewisville), told Texas medicine’s leaders he sees no permanent fix this year for Medicare’s Sustainable Growth Rate (SGR) formula. But, appearing at the TMA 2011 Advocacy Retreat via a Skype video call from his Capitol office, the only TMA member in Congress predicted “with 95-percent certitude” that “no cuts will happen” in physicians’ Medicare payments on Jan. 1.

Under current law, the SGR mandates a 27.4-percent cut when the new year begins. Dr. Burgess said he expects Congress will intervene at the last hour, again, stopping the cuts for two years with perhaps a small increase, while work for a permanent SGR replacement continues.

Meanwhile, the latest TMA survey says that almost half of Texas physicians are considering opting out of the Medicare program altogether, putting seniors, military families, and people with disabilities at serious risk of losing their doctor.
Given the partisan gridlock in Congress and the growing physician unrest, what can we do to replace the SGR with a formula that actually keeps up with the cost of seeing patients?

At TMA, we recognize the value that hospitals, nursing homes, home health services, durable medical equipment, and other health care providers give to Medicare patients. Over the past decade, they have received annual payment updates. Before any future updates are given to them, Washington needs to fix the broken physician payment system.

What do you think? Put your ideas in the comment box below, or tweet them to us, using the #MedicareMeltdown hashtag.

And while you're sharing your thoughts, have you seen our latest animated video, "Grandma & the Big, Bad SGR"? Take a look and let us know what you think. (We're quite proud of it.) Then share it with your colleagues, patients, family, friends, and staff. Use e-mail, Twitter, Facebook. Get the word out.



Dec 1, 2011

Grandma and the Big Bad SGR!



A huge Medicare cut looms for doctors and Medicare patients. Who might that affect? People like grandma - and those who love her, as the child in this video shows.

Unless Congress acts, on Jan. 1 doctors who care for Medicare patients face a 27.4-percent pay cut, because of a flawed funding formula called the SGR. Then millions of seniors (like grandma) and people with disabilities -- and military families whose insurance is TRICARE -- might have trouble finding a doctor's care.