July 2022 AUA Public Policy Council Update For MAS

From the Chair

I am pleased to share updates from the AUA Public Policy Council that may benefit your Section members. Our updates include information on the 2023 Medicare Physician Fee Schedule Proposed Rule and our successful advocacy to advance the adoption of telehealth.

CMS Releases 2023 Medicare Physician Fee Schedule Proposed Rule

On July 7, the Centers for Medicare and Medicaid Services (CMS) released the Calendar Year 2023 Medicare Physician Fee Schedule Proposed Rule (MPFS). At more than 2,000 pages the rule contains proposed policies that will affect the specialty of urology, highlighted below. The fact sheet provides information on many other proposed changes.

Conversion Factor
The conversion factor for 2023 is set to decrease by approximately 4.5% from $34.6026 to $33.0775. The decrease is due to the expiration of the 3% increase to payments that was enacted by law last year, but is due to expire at the end of 2022, which is then coupled with a mandated 0% increase.

Specialty Level Impact of the Proposed Changes
The impact table outlines the changes to overall payments to specialties. It projects that urology will face a 1% decrease in Medicare payments. The impact to group practices and the individual physicians, however, varies based on practice type and mix of patients and services provided to those patients. Note: the impact table in the proposed rule does not include the 3% cut as outlined above. It only includes impacts of rate-setting changes and changes to RVUs within the budget neutral system. AUA will be evaluating the impact more closely in the coming days.

Global Surgical Services
Of particular interest, CMS is seeking comment on “improving” payment for the global surgical package. As such, CMS is seeking comment on strategies that will make global surgical payment fair and equitable.

Evaluation and Management (E/M) Services
CMS is proposing to adopt nearly all the revisions for CPT® codes used to report other E/M visits including inpatient and observation services. The changes include revisions to the documentation guidelines and to the descriptors for these services, which will now mirror the revisions previously made to the outpatient E/M services. Inpatient E/M code level may be chosen based on time or medical decision making, and like the outpatient E/M codes, using the history and exam to determine code level has been eliminated.

Split/Shared Services
CMS has proposed to delay the much-debated split/shared services policy for another year, until 2024. In 2022, CMS finalized a proposal on how to determine the practitioner would bill the split/shared service based on CMS’ definition of substantive time. However, this policy was met with resistance by the AMA and other provider associations. Therefore, CMS allowed in 2022, that the substantive portion of a visit may be determined by who performed the history, physical exam or medical decision making or determined by more than half the total time spent with the patient.

Telehealth
CMS continues to support the use of telehealth in treating Medicare patients during the public health emergency. As such, the agency is proposing to retain certain services on telehealth list through 2023 to allow for data collection so that the agency may better understand the use of telehealth services within the Medicare program. Also included is a proposal to extend the use of codes that were placed on a temporary-approved telehealth list during the pandemic. The codes on the temporary list will be available for reporting telehealth services for 151 days at the end of the PHE.

AUA will continue to evaluate the rule in the coming weeks, as we begin to prepare our comment letter. In the meantime, please contact AUA Policy & Advocacy Director Ray Wezik at [email protected] with any questions or comments you may have.

Please Share: AUA Works to Survey Residents/Fellows on SPARC Act Program
The AUA’s Policy & Advocacy Resident Work Group is currently surveying residents and fellows to aid advocacy efforts for the Specialty Physicians Advancing Rural Care (SPARC) Act. We would like your help! The purpose of the survey is to gauge possible participation in the specialty physician loan repayment program outlined in the SPARC Act and to obtain additional data for advocacy purposes, including the amount of student loan debt and location of residency.

Please share the survey with the residents and fellows you work with!

The Policy & Advocacy Resident Work Group reports to the Legislative Affairs Committee and is comprised of medical students, residents and fellows. The work group aims to educate trainees about advocacy and is focused on increasing engagement among AUA advocacy priorities.

AUA Language on Telehealth Included in LHHS Appropriations Bill Report
On June 29, the House Appropriations Committee released the Report for the Departments of Labor, Health and Human Services (LHHS), and Related Agencies for Fiscal Year 2023 Appropriations, which included the AUA’s requested language on telehealth. The AUA drafted several telehealth provisions that, if enacted, would help ensure patients can continue to access care through telehealth. Data about telehealth usage can also be adequately collected to shape future policy. The AUA met with the staff of various House Appropriations Committee members to request the language be included in the report and we are pleased to see that language included with minimal changes. The House Appropriations Committee passed this bill on June 30. The measure is expected to be considered by the full House later this month.

The report language states the following:

• The Committee recognizes that demand for telemedicine increased in 2020 in response to the COVID–19 pandemic. In addition, the Committee notes disparities in telehealth exist between and within racial and ethnic groups, rural and urban locations, and geographic regions as detailed in a December 2021 report by the Assistant Secretary for Planning and Evaluation. The Committee urges the Secretary, working with CMS and HRSA, to categorize telehealth usage data, including for audio-only services, by Health Professional Shortage Areas. The Committee further urges the Secretary to work across agencies to ensure that improvements to broadband availability are prioritized in those areas with lowest telehealth usage, highest audio-only usage, and a known health professional shortage. The Committee requests an update within 120 days of the date of enactment of this Act on this categorization and broadband availability.

The AUA appreciates the inclusion of this language and looks forward to the vital collection of data to help shape permanent telehealth reimbursement.

AMA Endorses the AUA-led Specialty Physicians Advancing Rural Care (SPARC) Act
On June 10, the AUA received confirmation that the American Medical Association (AMA) formally agreed to endorse S. 4330, the Specialty Physicians Advancing Rural Care (SPARC) Act. The endorsement comes after months of work and negotiations with AMA staff. The AMA’s endorsement will go a long way in garnering additional support both on and off Capitol Hill for the SPARC Act. We also remain in contact with other larger organizations such as the American College of Surgeons and Association of American Medical Colleges in an effort to garner their support.

The AUA also continues to meet with Senate offices to garner cosponsors for the bill. On June 22, the AUA met with staff in the office of Senator Thom Tillis (R-NC) to discuss the senator cosponsoring S. 4330, the Specialty Physicians Advancing Rural Care (SPARC) Act. The senator’s staff showed an interest in the legislation because it would both increase the number of specialists North Carolina and help reduce the burden on patients in need of care.

On June 29-30, the AUA met with staff in the office of Senators Richard Durbin (D-IL), Deb Fischer (R-NE) and Richard Shelby (R-AL) to discuss co-sponsorship of S. 4330, the Specialty Physicians Advancing Rural Care (SPARC) Act. Overall, the senators’ staff were receptive to the legislation and the need to alleviate the specialty physician workforce shortage in rural America. They understand the SPARC Act benefits both specialty physicians burdened with student loan debt and rural patients needing specialty care in their respective states.

As a reminder, this legislation would establish a loan forgiveness program designed for specialty physicians who practice in a rural area for six years. Help advocate for the SPARC Act by contacting your U.S. Senators to ask them to cosponsor this legislation. Access the action center or simply text AUA to 52886 to get started.

AUAPAC Joins Fundraisers for Key House Committee Members

On June 14, AUAPAC, in conjunction with numerous other physician organizations, hosted a fundraiser for Representative Mike Kelly (R-PA-16). Rep. Kelly serves on the House Ways & Means Health Subcommittee, which has jurisdiction on many AUA priorities including the Medicare program. He is supportive of legislation that would expand access to care, including via telehealth, as well as measures to reduce regulatory burdens on physicians. During the event, the congressman expressed an interest in a variety of physician-related issues, including the need to find a long-term solution to impending Medicare cuts, workforce shortages and supply chain issues.

On June 15, AUAPAC participated in a fundraiser for Representative Julia Brownley (D-CA-26), hosted by a coalition of Medical and Dental Political Action Committees (MaDPAC). Rep. Brownley serves as the chair of the House Veterans’ Affairs Subcommittee on Health and is an advocate for reducing regulatory burdens and increasing access to urological research funding, particularly for bladder cancer. During the event, the congresswoman expressed her specific support for increasing the specialty physician workforce within the VA health system.

On June 22, AUAPAC participated in a fundraiser for Representative Brian Higgins (D-NY-26), hosted by MaDPAC. Rep. Higgins serves on the House Ways & Means Subcommittee on Health, which oversees the financing of key health programs such as Medicare. During the fundraiser, Rep. Higgins expressed his interest in issues facing the medical community, especially the need to reform the Medicare payment system, curbing prior authorization practices and increasing funding for graduate medical education training slots.

ICYMI: Updates from the AUA Policy & Advocacy Brief blog

AUA, ASM Urge House Committee Members to Improve Prior Authorization Processes
On June 27, the AUA joined the Alliance of Specialty Medicine (ASM) in a sign-on letter addressed to the House Energy and Commerce’s Oversight and Investigations Subcommittee urging action on H.R. 3173, the Improving Seniors’ Timely Access to Care Act. The bill works to improve the prior authorization process in Medicare Advantage (MA) plans. H.R. 3173 will better streamline the authorization process, reduce administrative burden, and will provide affordable access to care for patients.

Prior authorization is a process that requires physicians to obtain pre-approval for medically necessary treatments or tests prior to rendering care to patients. The prior authorization process can be a barrier for patients who are accessing medically necessary care due to the lengthy process and requirements that are needed to obtain approval.

The AUA continues to support legislation that improves the prior authorization process in efforts to reduce barriers for physicians providing care and for patients accessing care. To review a copy of the letter, please visit the AUA’s Policy & Advocacy Brief.

Below are insurance updates from national insurance carriers. If you have questions about insurer issues, contact Bhavika Patel at [email protected].

Aetna
Aetna reviewed its Genetic Testing (PA Medicaid) Policy adding medically necessary policy statement for genetic testing of FLI1 and updating the ICD-10 coding section.
Read the update.
Aetna reviewed its Vasectomy (Commercial) Policy adding a medically necessary statement for vasectomy reversal for the treatment of post-vasectomy pain syndrome.
Read the update.

BCBS Federal Employee Plan
BCBS Federal Employee Plan reviewed its ART/Infertility/Gender Dysphoria Drugs Prior Authorization (PA) Criteria with the following changes:
• Added brand Fyremadel to the policy
• Removed brands Clomid and Serophene
• Updated coverage statement for females over 50 years of age
Read the update.
BCBS Federal Employee Plan reviewed its Zytiga Prior Authorization (PA) Criteria adding the diagnosis non-metastatic very-high-risk prostate cancer with associated criteria.
Read the update.

CGS Administrators
CGS Administrators published its Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (MoIDX) (J15) (DL38997) Local Coverage Determination (LCD). The associated response to comments article can be found here.
Read the update.
CGS Administrators published its Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (MolDX) (A58713) Local Coverage Article (LCA). The article addresses billing and coding guidelines that complement the LCD for: “Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer” (MolDX) (L38997).
Read the update.
CGS Administrators published its response to Comments: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (MoIDX) (A59112) (J15) Local Coverage Article (LCA). A comment/response article was published for DL38997 Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (MoIDX).
Read the update.

Cigna
Cigna reviewed its Oncology (Erleada) (CA Commercial) Prior Authorization (PA) Criteria updating medically necessary criteria for Erleada for prostate cancer – non-metastatic, castration-resistant and prostate cancer – metastatic, castration-sensitive.
Read the update.
Cigna reviewed its Oncology (Xtandi) (CA Commercial) Prior Authorization (PA) Criteria updating medically necessary criteria for Xtandi for prostate cancer – castration-resistant (metastatic or non-metastatic) and prostate cancer – metastatic, castration-sensitive.
Read the update.
Cigna reviewed its Products Requiring Non-Preferred Coverage Review (CA Commercial) Policy adding applicable products with exception criteria including Besremi.
Read the update.

Humana
Humana reviewed its Urinary Bladder Dysfunction Policy removing HCPCS codes K1010, K1011, K1012.
Read the update.

National Government Services
National Government Services released its draft Biomarker Testing for Prostate Cancer Diagnosis (J06, JK) (DL37733) Local Coverage Determination (LCD) stating based on a reconsideration request, the test criteria have been revised to allow limited post-biopsy coverage and limited repeat testing coverage.
Read the update.
National Government Services issued a new version of its Water Vapor Thermal Therapy for LUTS/BPH (J06, JK) (L37808) Local Coverage Determination (LCD).
Read the update.

Noridian
Noridian retired its 4Kscore Assay (JE) (A57336) Local Coverage Article (LCA), effective June 12. This article is being retired because this is no longer within the scope of MolDX program. Noridian does not anticipate any claims for this service.
Read the update.
Noridian retired its 4Kscore Assay (JE) (L37120) Local Coverage Determination (LCD), effective June 11. This document is being retired because this is no longer within the scope of MolDX program Noridian does not anticipate any claims for this service.
Read the update.
Noridian retired its 4Kscore Assay (JF) (L37122) Local Coverage Determination (LCD), effective June 11. This document is being retired because this is no longer within the scope of MolDX program Noridian does not anticipate any claims for this service.
Read the update.

United Healthcare
United Healthcare reviewed its Prostate Surgeries and Interventions (Commercial West) Policy removing references to specific InterQual release dates; refer to the most current InterQual criteria to access medical necessity clinical coverage criteria.
Read the update. (Commercial West)
Read the update. (Value and Balance Exchange)
Read the update. (Commercial)

WPS Government Health Administrators
WPS Government Health Administrators released its draft 4Kscore Assay (DL37013) Local Coverage Determination (LCD) stating this test is no longer in the Moldx program. WPS is not receiving claims for this service; therefore, they would like to retire this LCD.
Read the update.
WPS Government Health Administrators released its draft MDx Epigenetic Molecular Assay (MolDX) (DL37005) Local Coverage Determination (LCD) stating the information in this LCD has been incorporated into our new MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (L39042) LCD. WPS would like to retire this LCD.
Read the update.

Local and Regional Updates
The following are updates in your Section. The AUA routinely monitors state legislative, regulatory, and insurance policy trends. Please contact AUA State Advocacy Manager Catherine Hendricks at [email protected] for more information on any of these issues.

Delaware
Highmark BCBS Delaware
Highmark BCBS Delaware archived its Treatment of the Prostate (Commercial) Policy as of May 2. For services rendered prior to the archived date of this policy, please refer to prior versions of this policy. For services rendered on or after May 2, refer to Medical Policy S-275, Prostate Cancer: Diagnosis, Staging, and Treatment.
Read the update.
Highmark
BCBS Delaware archived its Saturation Biopsy for Diagnosis and Staging of Prostate Cancer (Commercial) Policy, effective May 2. For services rendered prior to the archived date of this policy, please refer to prior versions of this policy. For services rendered on or after May 2, refer to Medical Policy S-275, Prostate Cancer: Diagnosis, Staging, and Treatment.
Read the update.
Highmark BCBS Delaware issues a new Prostate Disease: Diagnosis, Staging, and Treatment Policy stating saturation biopsy of the prostate may be considered medically necessary when criteria are met.
Read the update.

District of Columbia
DC B 24-0888 – Medical Business
Introduced by Councilmember Vincent Gray (D), DC B 24-0888 provides hospitals and healthcare service providers with a waiver to renew a certificate of need until 120 days after the end of the public emergency, if the certificate of need expired during or 30 days prior to the declaration of a public health emergency. The bill is before the Council for consideration.

DC B 24-0889 – Medical Business
Introduced by Councilmember Vincent Gray (D), DC B 24-0889 provides hospitals and healthcare service providers with a waiver to renew a certificate of need until 120 days after the end of the public emergency, if the certificate of need expired during or 30 days prior to the declaration of a public health emergency. The bill is before the Council for consideration.

Pennsylvania
Independence Blue Cross
Independence Blue Cross published its Experimental/Investigational Services Attachment A (Commercial) Supporting Coverage Document with the following changes:
• Added codes including 33268, 0672T, A2005
• Removed codes including 31647, 58674, 0404T
Read the update.

Maryland
CareFirst BCBS
CareFirst BCBS retired its Robotic Assisted Surgery Policy effective June 1.
Read the update.
CareFirst BCBS retired its Systems Pathology for Prediction of Recurrence of Prostate Cancer Policy effective June 1.
Read the update.

New Jersey
Horizon BCBS New Jersey
Horizon BCBS New Jersey published its new Post Payment Documentation Requests for Facility Claims (Medicaid, Medicare Medicaid Dual) Reimbursement & Billing Document.
Read the update.
Horizon BCBS New Jersey published its new Pre-Payment Documentation Requests for Facility Claims (Medicaid, Medicare Medicaid Dual) Reimbursement & Billing Document.
Read the update.
Horizon BCBS New Jersey reviewed its Prostatic Urethral Lift Policy removing medically necessary criterion that member does not have urinary retention.
Read the update.

A. 4385 – Medical Business
Introduced by Assemblymember Herb Conaway (D), A. 4385 makes revisions to the electronic medical records law and processes for recording patients’ demographic information. The cultural competency training, that hospitals and clinical laboratories are required to implement, are to include training on how to collect race, ethnicity, sexual orientation and gender identity in a culturally competent and sensitive manner. The bill was referred to the Assembly Budget Committee.

S. 2933 – Medical Business
Introduced by Senator Joe Cryan (D), S. 2933 makes revisions to the electronic medical records law and processes for recording patients’ demographic information. The cultural competency training, that hospitals and clinical laboratories are required to implement, are to include training on how to collect race, ethnicity, sexual orientation and gender identity in a culturally competent and sensitive manner. The bill was referred to the Senate Budget and Appropriations Committee.

Best regards,
Kathy and the AUA Public Policy & Advocacy Team