September 2022 AUA Public Policy Council Update For Mas

From the Chair
MAAUA Chair 2020

I am pleased to share updates from the AUA Public Policy Council that may benefit your Section members. Our updates include information on the AUA’s response to the Calendar Year 2023 Medicare Physician Fee Schedule Proposed Rule and multiple programmatic opportunities to engage in AUA advocacy.

A special thank you to Mid Atlantic Section member, Coding and Reimbursement Committee chair, and CPT Advisor Jonathan Rubenstein, MD, FACS for his participation in the AUA’s meeting with the Centers for Medicare and Medicaid Services last month.

Welcome Maureen Cones, Chief Legal and Policy Officer

It is with great pleasure that I am introducing my successor Maureen Cones, Esq. Maureen is the Chief Legal and Policy Officer for the American Urological Association. Maureen brings a wealth of legal and policy knowledge experience to AUA, having worked in Executive and General Counsel positions with responsibility for legislative and regulatory affairs and public policy for Walden University and as the Chief Legal & Compliance Officer for the American Nurses Association, where she worked from 2008-2019.  In her role at Walden University, Maureen was responsible for all legal, government relations and regulatory compliance strategy and support for all of the university’s healthcare education programs.  Maureen also brings to AUA a deep understanding of scope of practice, licensure, certification and accreditation and strategic leadership.

As a reminder, my last day at the AUA is October 17. Maureen will assume the leading role in public policy starting in September. Her contact information is phone: 410-689-3710; email: mcones@AUAnet.org.

Please join me in welcoming Maureen!

Reminder: AUA Gallagher Health Policy Scholar Application Open

As a reminder, the application window for the Gallagher Health Policy Scholar Program closes on October 14. This yearlong scholar program provides AUA members with opportunities to attend key health policy meetings, the Brandeis Health Leadership Program in Health Policy and Management and more. Highly seasoned AUA health policy volunteers mentor the Gallagher Scholar throughout their tenure. Please do not hesitate to reach out to Juliana Nicolini at jnicolini@auanet.org with any questions or any issues submitting an application.

AUAPAC Champions Program Seeking Applicants

The application process is now open for the AUAPAC Champions Program. The program is looking for individuals with a passion to promote the value of political giving for the specialty of urology, help to advance the house of urology’s legislative agenda and cultivate invaluable leadership, diplomacy and advocacy skills. To apply, you must:

If you are interested or know someone who may be, please apply or share the application form today! Applications close on September 30 and decisions made by October 17. If you have any questions, please contact the AUA’s Juliana Nicolini at JNicolini@AUAnet.org.

AUA Submits Comments on the Calendar Year 2023 Medicare Physician Fee Schedule Proposed Rule, Reiterates Concerns from Meeting with CMS

On September 1, the AUA submitted comments in response to the Calendar Year (CY) 2023 Medicare Physician Fee Schedule. Our comments to the Centers for Medicare & Medicaid Services (CMS) focus on the following:

  • Conversion Factor Update
  • CMS’s Proposed Valuation of Urology-Specific Codes for CY 2023 (Percutaneous Nephrolithotomy)
  • Evaluation and Management (E/M) Services
  • Payment for Medicare Telehealth Services
  • Requiring Manufacturers of Certain Single-dose Container or Single-use Package Drugs to Provide Refunds with Respect to Discarded Amounts
  • Strategies for Improving Global Surgical Package Valuation
  • Rebasing and Revising the Medicare Economic Index (MEI)
  • Strategies for Updates to Practice Expense Data Collection and Methodology
  • Medicare Potentially Underutilized Services
  • Merit-Based Incentive Payment System (MIPS) Value Pathways (MVPs)
  • Request for Information: Health Equity Measures

The AUA placed particular emphasis on CMS’ proposed valuation of urology-specific codes for Percutaneous Nephrolithotomy (PCNL) CPT codes (50080 and 50081), urging CMS to finalize the RUC-proposed values as it maintains the relativity of the procedures and accounts for the time, mental effort and skill associated with the codes. The AUA also signed onto comment letters regarding the proposed implementation of the clinical labor rate submitted to CMS by the Clinical Labor Coalition and the Alliance for Specialty Medicine.

The AUA’s comment letter is available online here. The AUA expects CMS to issue the CY 2023 Medicare Physician Fee Schedule final rule in early November 2022.

In developing this comment letter, the AUA met with CMS to discuss the issues outlined above, including valuation of specific urology codes, the implementation of the single-dose container and single-use package policy, and telehealth.

A special thank you to Public Policy Council chair Eugene Rhee, MD, MBA; Coding and Reimbursement Committee chair and CPT Advisor Jonathan Rubenstein, MD, FACS; Urology Telehealth Task Force chair Aaron Spitz, MD; and Coding and Reimbursement Committee member and RUC Advisor Thomas Turk, MD for participating in the call.

AUAPAC Chair Updates North Central Section on AUAPAC in 2022

This weekend, AUAPAC chair Robert Bass, MD, MBA, was invited to present on AUAPAC during the health policy session at the North Central Section’s Annual Meeting. During the presentation, Dr. Bass provided a history of AUAPAC, educated attendees on the role and purpose AUAPAC plays in advocacy efforts, and detailed the selection criteria AUAPAC uses when giving to candidates. Dr. Bass expressed his appreciation for the opportunity to represent the AUAPAC board at the NCS Annual Meeting.  “Being there reaffirms the great working relationship between the organizations,” said Dr. Bass.

AUAPAC is determined to continue educating domestic AUA members from all eight sections about AUAPAC and its role in successful urologic advocacy. The AUAPAC Board of Directors continues to seek additional opportunities to educate and engage AUA members this fall. If you are interested in having an AUAPAC session or presentation at your Section or specialty society meeting, please do not hesitate to reach out to LegislativeAffairs@AUAnet.org. As always, learn more about AUAPAC at www.myAUAPAC.org.

ICYMI: Updates from the AUA Policy & Advocacy Brief blog

AUA Cites Specialists’ Exclusion from National Health Service Corps in Highlighting the Need for SPARC Act

Over the last month, the AUA met with staff in the offices of Senators Maria Cantwell (D-WA), Kirsten Gillibrand (D-NY), Bob Casey (D-PA), Bill Cassidy, MD (R-LA) and Jeff Merkley (D-OR) to discuss co-sponsorship of the Specialty Physicians Advancing Rural Care (SPARC) Act (S. 4330).

During these meetings, Senate staff often comment that constituent outreach is critical in the decision to cosponsor the SPARC Act. You can help by contacting your Senators today to ask them to cosponsor this legislation. Take action now!

Sen. Cantwell’s staff was empathetic about the need for a program that helps alleviate specialty physicians’ burden regarding student loan debt and decisions about where they will practice. Sen. Cantwell’s staff also understood that such a program would help increase access to care in rural areas throughout the country, especially in Washington.

Sen. Gillibrand’s staff was understanding about the need for such a program because the National Health Services Corps (NHSC) does not include specialty physicians. Additionally, staff expressed interest regarding the program’s design, specifically incentivizing specialists to serve in rural areas, even in New York, where urologists are in high demand and short supply.

Sen. Casey’s staff appreciated the purpose of AUA’s advocacy for a specialty physician loan repayment program, especially since one does not currently exist. They recognized that the continued increase in student loan debt results in a disproportionate distribution of specialists in metropolitan areas resulting in a lack of access to specialty care in rural areas. AUA’s focus on these facts resulted in Sen. Casey’s staff expressing interest in the legislation because it aligns with Sen. Casey’s positions on access to care and physician workforce shortages.

Additionally, Sen. Cassidy’s staff understood how a specialty physician loan repayment program can financially support specialists so they can afford to work in rural America, which will increase access to specialty care. However, Sen. Cassidy’s staff expressed concern regarding the loan repayment structure, program financing and utilization of the program in rural states like Louisiana. They did appreciate the AUA bringing the bill to their attention in advance of the 118th Congress.

Sen. Merkley’s staff were generally supportive of the SPARC Act and appreciated efforts to increase access to specialty care in rural communities. While they did raise questions regarding how the Health Resources & Services Administration might define specialty physicians and rural communities, they would like to continue the discussions going into the 118th Congress.

AUAPAC Participates in Fundraiser for Senate Finance and HELP Committees Member

On September 8, AUAPAC participated in a fundraiser for Senator Maggie Hassan (D-NH), hosted by a coalition of Medical and Dental Political Action Committees (MaDPAC). Sen. Hassan serves on the Senate Finance Committee, Senate Veterans’ Affairs Committee and Senate Health, Education, Labor & Pensions (HELP) Committee, which has jurisdiction over most of the agencies, institutes and programs of the Department of Health and Human Services. During the fundraiser, Sen. Hassan expressed support for issues facing the medical community, especially the need to reform the Medicare payment system and curbing Medicare Advantage prior authorization practices.

No Surprises Act Final Rule

The Departments of Labor, Health and Human Services (HHS), and the Treasury issued the Final Rules and FAQs on the No Surprises Act (NSA) which address several provisions of the payment process for out-of-network care. Specifically, the document finalizes disclosure requirements relating to information that group health plans and health insurance issuers must share about the qualifying payment amount (QPA) under the interim final rules (IFR) issued in July 2021.  It also finalizes select provisions under the October 2021 IFR to address requirements related to the consideration of information when a certified independent dispute resolution (IDR) entity makes a payment determination under the Federal IDR process.

The Final Rules remove the requirements on the arbiter to presume that the QPA is the appropriate out-of-network rate and states that arbiters should select the offer that best represents the value of the service. The Final Rules also clarify that the initiating party to an open negotiation is always permitted to send the standard Federal initiation notice, requires plans to provide information on why a claim was downcoded if the QPA is based on a downcoded service or modifier and clarifies that plans must calculate QPAs separately for each physician specialty to address the impact of non-negotiated contract rates on the median.

The Final Rules are effective 60 days after the date of publication in the Federal Register. The AUA is currently reviewing the Rule’s impact on urology and will provide a detailed summary.

CMS Releases Health Care System Resiliency, Medicare Waiver Fact Sheets

CMS is beginning to release fact sheets to prepare healthcare providers for the eventual end of the COVID-19 Public Health Emergency (PHE) and the emergency waivers and flexibilities put into place early in the pandemic. The Health Care System Resiliency Fact Sheet is linked below.

Health Care System Resiliency Fact Sheet

In addition, CMS is making healthcare providers aware that pre-pandemic health and safety standards for billing practices will need to be re-established. CMS’ fact sheets are available to healthcare providers in an effort to help guide the healthcare sector through the transition of operations once the PHE ends. Additional CMS fact sheets released on August 19 summarize the current status of the Medicare waivers and flexibilities as well as the Medicaid flexibilities that are separated by provider type.

The AUA continues to monitor the status of the PHE to assist in providing physicians and patients with next steps in reimbursement and access to care.

Below are insurance updates from national insurance carriers. If you have questions about insurer issues, contact Bhavika Patel at bpatel@AUAnet.org

Aetna

Aetna reviewed its Benign Prostatic Hyperplasia Policy adding CPT code 0714T to the non-covered list.

Read the update.

Aetna reviewed its Botulinum Toxins (PA Medicaid) Prior Authorization (PA) Criteria updating the age limit for Botox for neurogenic bladder.

Read the update.

Aetna reviewed its Urological Supplies (Commercial) Policy removing codes K1010-K1012.

Read the update.

Anthem

Anthem reviewed its Infertility and HCG Agents policy adding gender dysphoria as an approved indication for agents for fertility preservation, along with associated criteria.

Read the update.

BCBS Federal Employee Plan

BCBS Federal Employee Plan reviewed its ART Drugs Policy updating hypogonadism requirements to clarify that hypogonadism must be hypogonadotropic to meet criteria.

Read the update.

BCBS Federal Employee Plan published its new Pluvicto Pharmaceutical Policy stating Pluvicto may be considered medically necessary when criteria are met.

Read the update.

BCBS Federal Employee Plan issued its new Tumor Informed Circulating Tumor DNA Testing for Cancer Management Policy stating tumor-informed circulating tumor DNA testing (Signatera) is considered not medically necessary for all indications.

Read the update.

CGS Administrators

CGS Administrator reviewed its Next-Generation Sequencing Lab-Developed Tests for Inherited Cancer Syndromes (MoIDX) (J15) (A58734) Local Coverage Article (LCA) with the following change:

  • Under CPT/HCPCS codes group 2: codes deleted 81162, as the addition of this code in revision 1 was done in error.

Read the update.

CGS Administrators reviewed its Prognostic and Predictive Molecular Classifiers for Bladder Cancer (MolDX) (A58065) Local Coverage Article (LCA) revising the code description for CPT Code 0016M due to the third quarter 2022 CPT/HCPCS code update, effective July 1.

Read the update.

CGS Administrators retired its draft Prostate Cancer Detection with IsoPSA (J15) (DL39124) Local Coverage Determination (LCD), effective August 17. This draft LCD has been moved to the MCD archive site without being released to a final LCD version.

Read the update.

Cigna

Cigna reviewed its Genetic Testing (Collateral File) Medical Policy adding Cxbladder Monitor, and Decipher Bladder.

Read the update.

FDA

FDA reviewed its Recent New and Generic Drug Approvals Drug Administrative Document adding Nubeqa.

Read the update.

Noridian

Noridian reviewed its Prognostic and Predictive Molecular Classifiers for Bladder Cancer (MoIDX) (JE) (A58181) Local Coverage Article (LCA) revising the code description for CPT Code 0016M due to the third quarter 2022 CPT/HCPCS code update, effective July 1.

Read the update. (JE, A58181)

Read the update. (JF, A58187)

Noridian retired its 4Kscore Assay (JF) (A57337) 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 issued a new version of its Positron Emission Tomography Scans Local Coverage Article (LCA) with the following changes:

  • Added HCPCS A9596 to code group 19 effective July 1.
  • Added the statement “Effective May 10, PSMA-PET/CT or PSMA-PET/MRI with Gallium 68-ga Gozetotide/PSMA-11 may be used to screen patients for Pluvicto eligibility per NCCN Guidelines and SNMMI AUC” to group 19.
  • Added the PI modifier and following statement “NOTE: The PI modifier must be billed with C79.81 along with one of the C50.XXX diagnosis codes listed below AND the KX modifier to attest the initial anti-tumor treatment strategy is for male and female breast cancer only when used in staging distant metastasis per NCD 220.6.17.2.B1a effective 1/1/2021” to code group 14.

Read the update. (JE, A54666)

Noridian

Noridian retired its ConfirmMDx Epigenetic Molecular Assay (JE) (A57605) Local Coverage Article (LCA), effective August 8. The information in this article has been incorporated within the Billing and Coding: MolDX Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer A58718.

Read the update.

Noridian retired its ConfirmMDx Epigenetic Molecular Assay (JF) (A57606) Local Coverage Article (LCA), effective August 8. The information in this article has been incorporated within the Billing and Coding: MolDX Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer A58724.

Read the update.

Noridian retired its ConfirmMDx Epigenetic Molecular Assay (MolDX) (L36327) Local Coverage Determination (LCD), effective August 8. The contractor states that the information in this policy has been incorporated within the MolDX: Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer L37750.

Read the update.

Noridian retired its ConfirmMDx Epigenetic Molecular Assay (MolDX) (L36329) Local Coverage Determination (LCD), effective August 8. The contractor states that the information in this policy has been incorporated within the MolDX: Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer L37748 LCD.

Read the update.

Noridian retired its MolDX: Progensa PCA3 Assay Billing and Coding Guidelines (A54489) Policy, effective August 8. The information in this article has been incorporated within the Billing and Coding: MolDX Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer A58718.

Read the update.

Noridian retired its MolDX: Progensa PCA3 Assay Billing and Coding Guidelines (A54492) Policy, effective August 8. The information in this article has been incorporated within the Billing and Coding: MolDX Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer A58724.

Read the update.

Novitas

Novitas issued a new version of its Medicare Part B Redetermination and Clerical Error Reopening Request Form Appeals Form.

Read the update.

Palmetto

Palmetto reviewed its Prognostic and Predictive Molecular Classifiers for Bladder Cancer (MolDX) (JJ, JM) (A58028) Local Coverage Article (LCA) revising the code description for CPT code 0016M due to the third quarter 2022 CPT/HCPCS code update, effective July 1.

Read the update.

United Healthcare

United Healthcare reviewed its Prostate Services and Procedures Medical Policy removing cryosurgery of the prostate from applicable procedures with associated guidelines and adding a notation for procedures not addressed in this policy.

Read the update.

Read the update. (JF, A54668)

United Healthcare reviewed its Genetic Testing (Medicare) Policy updating the table of molecular diagnostic genetic tests included in the Palmetto MolDX Program.

Read the update.

United Healthcare retired its Cavernous Nerves by Electrical Stimulation with Penile Plethysmography (NCD 160.26) (Medicare Advantage) Policy, effective July 13.

Read the update.

United Healthcare retired its Cryosurgery of Prostate (NCD 230.9) (Medicare Advantage) Policy, effective July 13.

Read the update.

United Healthcare retired its Prostate Cancer Screening Tests (Medicare Advantage) Policy, effective July 13.

Read the update.

United Healthcare reviewed its Omnibus Codes (Individual Exchange) Coding Document with the following changes:

  • Removed CPT code 0596T
  • Updated conclusion from unproven to proven in certain circumstances for CPT code 53899

Read the update.

United Healthcare reviewed its Zytiga Prior Authorization (PA) Criteria with the following changes:

  • Added very-high-risk members receiving external beam radiation therapy prostate cancer criterion
  • Removed no disease progression with another formulation prostate cancer criterion

Read the update.

WPS Government Health Administrators

WPS Government Health Administrators retired its Progensa PCA3 Assay (MolDX) (A55202) Local Coverage Article (LCA), effective July 2. Progensa has been incorporated into the new article A58759 Billing and Coding: MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer.

Read the update.

WPS Government Health Administrators reviewed its ProMark Risk Score (J05, J08) (A57587) Local Coverage Article (LCA) adding the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.1.2 A/B MAC (B) Contacts with Independent Clinical Laboratories to CMS National Coverage Policy section.

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 chendricks@AUAnet.org for more information on any of these issues.

Additional State Updates

State Telemedicine Waivers Update

Since the COVID-19 pandemic began, the Federation of State Medical Boards has maintained charts documenting state waivers on out-of-state physicians practicing in-person and via telemedicine, as well as expediting licensure for inactive or retired physicians. As of August 15, 11 states are still allowing applications for out-of-state physicians to practice in person, ten via telemedicine, and seven are expediting licensure for inactive or retired physicians. Find the charts here.

Interstate Medical Licensure Compact: New States and Proposed Amendments

The Interstate Medical Licensure Compact (IMLC) has had a banner year so far in 2022: In January, New Jersey joined the Compact; Indiana joined in March, followed by Connecticut in May, and most recently, Rhode Island in July. The IMLC is now comprised of 39 Member States—37 states, the District of Columbia and Guam. Currently, there is IMLC legislation pending in New York A. 10559 and North Carolina S.B. 380.

The Interstate Medical Licensure Compact (IMLC) is also proposing amendments to IMLC Rule Chapter 6 – Rule on Coordinated Information System, Joint Investigations and Disciplinary Actions. A copy of the proposed amendments can be found at: IMLCC Rulemaking Information page.

The proposed amendments seek to clarify how a disciplinary action taken by an IMLC member board against a licensee is considered for unprofessional conduct and if the licensee may be subject to discipline by other IMLC member boards consistent with that state’s Medical Practice Act.

The proposed amendments restrict an IMLC member board from issuing a subpoena to another IMLC member board for information regarding what would otherwise be the lawful practice of medicine in the state at the time of service. These proposed changes seem to be in response to the differences between state laws regarding transgender care and abortion services.

District of Columbia

D.C. B 24-0917 – Medical Business ENACTED

Introduced by Councilmember Elissa Silverman (I), D.C. B 24-0917 outlines the limitations of a non-compete agreement between an employer and physician. The agreement must specify the functional scope, including what services, roles, industry or competing entities the employee is restricted from performing; the geographical limitations of the work restriction and if the employee is a medical specialist, the non-compete must not exceed 730 calendar days from the termination of employment. The agreement must be provided by the employer, in writing, 14 days prior to the individual beginning employment. Mayor Muriel Bowser (D) signed the bill into law on August 15.

Pennsylvania

Independence Blue Cross

Independence Blue Cross reviewed its Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH) (Medicare Advantage) Policy adding CPT code 0714T as experimental/investigational.

Read the update.

Best regards,

Maureen and the AUA Public Policy & Advocacy Team