Blogs

Each week, the AUA publishes weekly updates on the latest insurance issues pertaining to urology. This week’s update includes new policies from AlohaCare and UPMC, revisions to current policies from Aetna, AmeriHealth, BCBS North Carolina, BlueAdvantage, Horizon, and HealthNet, and updates in Prior Authorization (PA) criteria from ArchCare, BCBS Minnesota, Highmark, Premera, and Tufts Health Plan. Also, there are two Local Coverage Articles (LCAs) from WPS Government Health Administrators. Please see below for additional details on each policy update. Aetna Aetna has reviewed and updated its ablative procedures for prostate cancer medical policy with the ...
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On February 18, 2020, Congressmen David McKinley (R-WV-1) and Peter Welch (D-VT-AL) introduced a bill that would help to address the workforce shortage of specialty physicians in rural America (H.R. 5924). This bipartisan bill would create a student loan repayment program for specialty physicians that practice in rural communities for a minimum of six years. While student loan forgiveness programs exist through agencies like the National Health Service Corps, none of them are open to specialty care physicians such as urologists. The AUA worked closely with Rep. McKinley and his staff to develop this legislation, and stands in support of H.R. 5924. This bill ...
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On February 3, Maryland House Delegate Erek Barron (D-24) introduced HB 852 to specifically require the state of Maryland to cover a digital rectal exam and a PSA test for men between 40 and 75 years old and men who are at high risk of developing the disease. Following the introduction, on February 13, the legislation was heard by the Health and Governance Operations Committee where AUA Mid-Atlantic Section President Dr. Benjamin Lowentritt testified in support of the bill. To listen to the hearing, click here (hearing begins at the 1:45:45 mark; Dr. Lowentritt’s testimony begins at the 1:54:44 mark ) “This is about incorporating prostate cancer ...
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On February 7, the AUA and Bladder Cancer Advocacy Network (BCAN) met with appropriations staff from Congressman Dutch Ruppersberger’s (MD-02) office to discuss Fiscal Year (FY) 2021 appropriations funding for bladder cancer under the Department of Defense’s Congressionally Directed Medical Research Program (CDMRP). The collaborative meeting discussed the need for bladder cancer to have its own $10 million line within the CDMRP. Since 2016, bladder cancer has resided within the Peer Reviewed Cancer Research Program (PRCRP) that entails sharing a pot of funding with multiple disease areas. In FY 2019, bladder cancer received $8.7 million of the total $90 million ...
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On February 11, AUA Legislative Affairs Committee Member Dr. Jason Jameson and AUA staff participated in a meet and greet with Rep. Salud Carbajal (D-CA-24). The congressman serves on the House Armed Services, Budget, and Transportation & Infrastructure committees. During the meeting, Dr. Jameson talked about his work to increase access for men’s health – including the need for better mental health education – and the work the AUA is doing to create an Office of Men’s Health under the Department of Health and Human Services. Rep. Carbajal expressed his interest in this effort, particularly the part of ensuring that more boys and men are properly screened ...
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On February 11 and 12, the House Education & Labor and Ways & Means Committees held markups on two separate pieces of legislation to address the issue of surprise medical bills. The Ban Surprise Billing Act (H.R. 5800) was passed out of the Education & Labor Committee by vote of 32 to 13, with the dissenting votes being a mix of Democrats and Republicans. The bill has limited to no support from the physician community, as it would – among other issues – rely on a benchmark of the median in-network rate for disputes of $750 and under. The bill is very similar to legislation that was passed out of the House Energy & Commerce Committee in July 2019. ...
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The Food and Drug Administration (FDA) announced several supplements promoted for sexual enhancement have been found to contain undeclared active ingredients.  The presence of undeclared active ingredients renders the products unapproved drugs for which safety and efficacy has not been established and, therefore, subject to recall.  The products and the active ingredients contained include: Alpha-Male (sildenafil and tadalafil) OrgaZEN Gold 5800 (sildenafil) XXX Platinum WOODIE (sildenafil and tadalafil) Sildenafil and tadalafil are FDA approved drugs for the treatment of male erectile dysfunction.  While there are no reports of illness associated ...
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In a recent blog post , Centers for Medicare & Medicaid Service (CMS) Administrator Seema Verma announced that CMS will make changes to its various Compare tools.  Currently CMS maintains separate Compare webpages on Medicare.gov for hospitals, nursing homes, home health, dialysis facilities, long-term care hospitals, inpatient rehabilitation facilities, physicians, and hospice.  The goal of these tools is to help Medicare participants and others make informed healthcare decisions and to incentivize these healthcare entities to maximize their performance.  Administrator Verma notes, “each (tool) functions independently with varying user interfaces that ...
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Are you an “exceptional performer” in the Merit-based Incentive Payment System (MIPS)? In the 2020 performance year anyone who scores 85 points or higher will get an exceptional performance bonus; this is a bonus that is on top of the MIPS participation incentive. Considering that MIPS incentive payments are lower than the Centers for Medicare & Medicaid Services (CMS) originally predicted, it is important to ensure that participants are scoring as high as possible and getting that extra bonus. Take advantage of the AUA’s free webinar featuring experts from CMS, who will explain how to become an exceptional performer.  The webinar on Tuesday, March 10, 2020, ...
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On a recent webinar, Centers for Medicare & Medicaid Services (CMS) staff stated that submitting any information for the Promoting Interoperability category voids a hardship exemption. This submission could be as little as submitting your name or tax identification number. So, if participating individuals or groups think they may apply for a hardship exemption, they should not do not do anything related to Promoting Interoperability reporting. MIPS eligible clinicians, groups, and virtual groups may qualify for hardship exemption from Promoting Interoperability if they: Are a small practice (15 or fewer providers); Have decertified electronic health ...
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Each week, the AUA publishes weekly updates on the latest insurance issues pertaining to urology. This week’s update includes updates from Blue Cross Blue Shield (BCBS) North Carolina, CareAllies/Cigna, EviCore Healthcare, Health Alliance Plan of Michigan HealthNet, Kaiser Permanente, Medica Healthcare Plans Florida, National Government Services (NGS) and WPS Government Health Administrators. Please see below for further detail about each update. BCBS North Carolina IMRT Prostate - Med Policy: This policy was reviewed and updated with the following changes to criteria and supporting information: Added use in patients with low metastatic burden prostate ...
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The top takeaways from the Centers for Medicare & Medicaid Services (CMS) February Clinician Outreach Meeting focused on the Open Payments Program updates, updated Medicare coverage guidelines related to acupuncture for chronic low back pain, and stakeholder feedback on ways to improve the Claims Appeals Process. Open Payments Program Update CMS currently is conducting an annual refresh of Open Payments Program data. The new data will be published on or by June 30. If a clinician is not registered already in the Open Payments system, CMS recommends that they do so as soon as possible. The next dispute period opens on April 1. CMS will be hosting a ...
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Each week, the AUA publishes weekly updates on the latest insurance issues pertaining to urology. This week’s update includes revised polices from Aetna regarding Benign Prostatic Hyperplasia (BPH) and Neurogenic Bladder, Selected Treatments, as well as two new policies from Coordinated Care Health Plan regarding Gene Expression Profile Testing of Cancer Tissue and Intensity-Modulated Radiotherapy. Also, HealthPartners revised and updated its Botox medical policy, and LifeWise Health Plans and Premera updated their Prostate Cancer Targeted Therapies policy. Furthermore, Medical Mutual updated its Hormone Replacement Therapy Patches policy, and there is updated ...
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Lawmakers in Vermont, Hawaii and Georgia introduced bills in January to address the issue of surprise billing, while legislation moved forward in the state of Michigan. At least eight states currently have active legislation in play on this important issue. On January 16, Vermont State Senator Virginia Lyons (D) introduced SB 309, a bill prohibiting certain provisions in contracts between health insurers and health care providers. It also would limit patient’s out-of-pocket exposure for emergency services delivered at out-of-network health care facilities and for non-emergency services delivered by out-of-network providers at in-network facilities. SB 309 ...
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Two urologists and AUA members - Dr. William Figlesthaler of Florida and Dr. Tom Tarter of Illinois – are vying for seats in the 117 th Congress. Dr. Tarter, of Champaign, IL, is seeking to unseat incumbent Senator Dick Durbin (D), who has served in his office since 1997. He is a graduate of Albany Medical College, has served on the Health Policy Council of the North Central Section of the AUA, and is the Chairman of the Decatur Memorial Hospital Cancer Committee. Dr. Figlesthaler, of Naples, FL, announced his bid to represent Florida’s 19 th District in the House of Representatives – a seat currently held by Rep. Francis Rooney (R), who will retire at ...
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Growth in the Medicare Part D program, redesigning the Medicare Advantage (MA) quality bonus program and assessing payment adequacy and updating payments were among the topics in the January 2020 meeting of the Medicare Payment Advisory Commission (MedPAC). MedPAC is an independent Commission whose primary role is to advise Congress on issues affecting the Medicare program. It does so through two reports: Its March report on Medicare Payment Policy, and a June report on Medicare and the Health Care Delivery System. The Medicare Prescription Drug Program (Part D): Status Report and Options for Restructuring MedPAC staff presented a status report of the ...
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The top takeaway from the CMS January 29 Listening Session on MAC Opportunities to Enhance Provider Experience call focused on stakeholder input on ways CMS and MACs could improve the provider experience, and reduce burdens on the provider. Call participants pointed to the following as concerns or opportunities for improvement: Requiring MACs to work together and create identical policies is extra work and is no longer transparent. Discussions regarding Local Coverage Determinations (LCDs) are no longer held in face-to-face meetings and often, LCDs are written in different jurisdictions and are not always applicable across the board. Currently, various ...
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The top takeaway from the Centers for Medicare & Medicaid Services (CMS) January Open Door Forum focused on prior authorization for certain hospital outpatient department (OPD) services and the Open Payments Program. Prior Authorization for Certain Hospital OPD Services Effective July 1, 2020, the following OPD services will require prior authorization: Blepharoplasty Botulinum toxin injections Panniculectomy Rhinoplasty Vein ablation The full list of HCPCS codes requiring prior authorization is available here (PDF) .  CMS will post additional information about this program here including where to submit the information for prior ...
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The Centers for Medicare and Medicaid Services (CMS) recently released the final 2018 performance data for the Quality Payment Program (QPP). The QPP encompasses two entities:  the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM). Nearly all urologists participated in MIPS in 2018. Therefore this summary will focus on MIPS statistics. However, information about APMs as well as additional MIPS data is available through the CMS blog post and 2018 Quality Payment Program Performance Year Data Infographic . Points of Interest 98 percent of eligible clinicians (889,995) participated in MIPS in 2018—up from 95 percent ...
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The Centers for Medicare & Medicaid Services (CMS) recently released introductory materials (including a video , webpage and overview fact sheet ) about MIPS Value Pathways (MVPs) reporting. In the 2020 Physician Fee Schedule final rule, CMS announced that MVP reporting will begin in 2021. CMS sees this new option as a way to simplify Merit-based Incentive Payment System (MIPS) reporting as well as transition participants into Advanced Alternative Payment Model (APM) reporting. CMS hopes that MVP reporting will eventually replace MIPS reporting. Throughout 2020, CMS will present a variety of information about MVP reporting to educate participants. Take ...
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