Constituent policy

Medicare offers physician compensation and policy changes via fee schedule

Medicare’s proposed 2023 Physician Fee Schedule (PFS) proposes changes to telehealth policies, treatment for opioid use disorder, and dental services, as well as a limited use plan fee-for-service funds to meet social needs.

In addition, the proposed rule would expand opioid treatment and recovery services, including an offer for broader use of mobile units, such as vans, to increase access for people who are homeless or living in rural areas.

The Centers for Medicare & Medicaid Services (CMS) released the draft rule on Thursday which also addresses behavioral health services, accountable care organizations (ACOs) and colorectal cancer screening.

CMS said the proposed rule reflects current law, including maintaining a flat key conversion factor or updating to 0%. This combined with the expiration of the 3% increase in PFS payments for 2022 means that the proposed PFS conversion factor for calendar year (CY) 2023 is $33.08, a decrease of $1.53 compared to the CY 2022 PFS conversion factor of $34.61, CMS said.

While staff at physician organizations will need time to fully review the draft rule, which is approximately 2,066 pages, the American Medical Association (AMA) expressed immediate dissatisfaction with certain aspects of it. .

“It is immediately apparent that the rule not only fails to account for practice cost inflation and COVID-related challenges to practicing sustainability, but also includes a significant and damaging across-the-board reduction in payout rates,” said WADA President Jack Resneck. Jr., MD, in a statement.

Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association (MGMA), said his group was “incredibly concerned” about a proposed 4.42% reduction in the conversion factor that occurs for a period inflation, ongoing COVID-19 pandemic issues, and a personnel crisis.

“These proposed reductions, coupled with the 4% PAYGO sequestration due to take effect January 1, 2023, will adversely impact group practices,” Gilberg said.

In contrast, the National Association of Responsible Care Organizations (NAACO) was quick to welcome the proposed rule. In a statement, NAACO chief executive Clif Gaus, ScD, said the proposed changes would help advance CMS’s goal of ensuring that every person is enrolled as a Medicare beneficiary in a relationship with a clinician responsible for its quality and the total cost of care by 2030. .

“Importantly, the changes proposed today by the CMS projects would save Medicare more than $15 billion and yield $650 million in higher shared savings payments to ACOs. We know that the most effective alternative payment models are those where providers are held accountable for patient outcomes year-round, as ACOs do,” said Gaus.

Below is a summary of some of the major policy changes in the proposed rule:


CMS has offered to make several services that are temporarily available as telehealth services due to the public health emergency (PHE) available until 2023 on what is called a Category III basis.

This will allow more time for data collection that could support their eventual inclusion as permanent additions to Medicare’s list of telehealth services, CMS said. The agency is also proposing to extend the length of time that services are temporarily included on the list of telehealth services during PHE but are not included on a Category I, II or III basis for a period of 151 days following the end of PHE.

Behavioral health

The proposed rule also includes a plan for licensed professional counselors, marriage and family therapists, and other types of behavioral health practitioners to provide behavioral health services under general (rather than direct) supervision. Additionally, CMS also offers to pay licensed clinical psychologists and clinical social workers to provide integrated behavioral health services as part of a patient’s primary care team.

chronic pain

CMS said it is proposing to bundle certain chronic pain management and treatment services into new monthly payments, improving patient access to comprehensive, team-based chronic pain treatment.

Using the new Common Health Care Procedures Coding System codes and evaluating chronic pain management and treatment services would encourage more practitioners to welcome more Medicare-registered pain sufferers into their practices. chronicle, CMS said. These proposed changes could also encourage practitioners who already treat Medicare-enrolled sufferers to spend time “helping them manage their condition as part of a trusted, supportive, and ongoing care partnership,” it said. CMS.


CMS offers a way to use funds from some new Medicare Shared Savings Program ACOs to meet social needs.

“It is expected that this proposal, if finalized, will be an opportunity for many providers in rural and other underserved areas to come together as ACOs, build the infrastructure needed to succeed in the program and promote equity by holistically addressing patient needs, including social needs,” CMS said in a fact sheet.

CMS also proposes that smaller ACOs have more time to transition to downside risk, helping to increase participation in rural and underserved communities. The agency also proposed a health equity adjustment to an ACO’s quality performance category score to reward excellence in care for underserved populations.

Colon cancer screening

CMS only offers monitoring colonoscopy at-home testing would be considered a preventative service, meaning that cost-sharing would be waived for people on Medicare. Additionally, Medicare is offering to cover the service for those age 45 and older, consistent with the newly lowered age recommendation, instead of age 50.

Dental services forming an integral part of covered medical services

Medicare Part B currently pays for dental services when the service is an integral part of the medically necessary services required to treat a primary medical condition, such as jawbone reconstruction following an accidental injury.

In the draft 2023 compensation rule, CMS proposes to cover more dental services, such as examination and treatment preceding an organ transplant.

In addition, CMS is seeking input on other medical conditions for which Medicare should pay for dental services, such as cancer treatment or joint replacement surgeries, as well as a process for seeking public input when additional dental services can be integral to clinical success. other medical services.

Opioid use disorder

CMS said it is looking to increase overall payments for drug treatment and other treatments for opioid use disorder (OUD), recognizing that longer therapy sessions are usually needed.

Based on the severity of needs of the patient population diagnosed with OUD receiving services in treatment programs, CMS proposed to change the payment rate for the non-drug component of the bundled payments for episodes of care to base the individual therapy rate on a crosswalk code describing a 45-minute session, rather than the current crosswalk code describing a 30-minute session.

CMS is also proposing to allow the additional Opioid Treatment Program (OTP) admission code to be provided via two-way audio-video communication technology when billed for treatment initiation with buprenorphine. This would apply to the extent that the use of audio-video telecommunications technology to initiate buprenorphine treatment is authorized by the Drug Enforcement Administration (DEA) and substance abuse and the Mental Health Services Administration (SAMHSA) at the time the service is provided.

The federal agency also proposes to allow the use of audio-only communication technology to initiate buprenorphine treatment in cases where audio-video technology is not available to the recipient and all other applicable requirements are fulfilled.

Additionally, CMS said it would clarify policy so that opioid treatment programs can bill Medicare for medically reasonable and necessary services provided through mobile units in accordance with SAMHSA and DEA guidelines. CMS proposes that locality adjustments for services provided via mobile units be applied as if the service were provided at the physical location of the OTP registered with DEA ​​and certified by SAMHSA.

Kerry Dooley Young is a freelance journalist based in Miami Beach, Florida. She is responsible for the central theme of patient safety issues for the Association of Health Care Journalists. Follow her on Twitter at @kdooleyyoung.

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