MMS Testimony Relative to Proposed Amendments to MassHealth Billing Regulations

The Massachusetts Medical Society wishes to convey its strong disagreement with the proposed amendments to MassHealth administrative and billing regulations (130 CMR 450.000). These regulations would place an unreasonable timeline on the new requirement that all physicians become MassHealth providers—either billing or non-billing— and would substantially alter the billing practices for physician-led health care teams by disallowing the longstanding practice of “incident-to” billing. The Medical Society thus strongly urges reconsideration of the timeline of the MassHealth provider mandate and urges the striking of 130 CMR 450.212E(4) which functionally prohibits incident-to billing.  Passage of these regulations without MMS’ suggested changes, as outlined below, could jeopardize the sustainability of MassHealth physician provider participation in Massachusetts and place many physicians and medical staff administrators in a position whereby, in six weeks’ time, countless physicians would find themselves unintendedly out of compliance with medical licensure law.  

The Medical Society has long supported physician-led team based health care that utilizes many different health care professionals, including advanced practice registered nurses (APRNs) and physician assistants, to optimize access to and quality of medical care- ideals that are important to the MassHealth program. Incident-to billing, that is, the practice of billing select services by health care teams members such as nurse practitioners under the physicians NPI, appropriately reflects the complexity of team-based care. While nurse practitioners or physician assistants may provide the bulk of the care after initial service by the physician, the physician retains a supervisory and consultative function to the clinician and to the patient. These are tangible, important functions to ensure optimal quality of care for patients. These tasks carried out by the physicians include in-person consultation with the clinician and/or the patient, retrospective chart review or case discussion, and other quality assurance activities. These practices by physicians are particularly important to ensuring quality of care of pediatric patients or patients with complex medical issues- two key patient populations for the MassHealth program. Physicians also spend time assisting in the medication management of advanced practice nurses in MA, especially since most APRNS are statutorily required to prescribe pursuant to guidelines mutually developed with a physician. It is essential that incident-to billing, which is designed to capture the entire team-based care episode, be retained to promote these best practices. Additionally, incident-to billing is not reserved solely for the office setting: physicians often utilize the bill code for shared office visits or for instances in which a physician provides care in an emergency room.

The proposed changes are further troubling as they would part from Medicare’s longstanding and widely recognized recognition of incident-to billing. With the ever-complicating nature of billing and coding, this only further perpetuates the problem of inconsistent policies between payers.

MassHealth funding levels already create strain on many physician practices. Eliminating incident-to billing would further exacerbate the reimbursement issue: not only would physicians be under-reimbursed for the level of care that they directly provide and bill for, but they would also no longer be compensated for all of the supervisory and consultative tasks that they undertake when care is provided by advanced practice nurses or physicians assistants. This 15% reduction that would occur if indecent-to billing is prohibited could reduce the supervisory or consultative safeguards that many physicians implement in their offices, or could further discourage participation as MassHealth providers. Furthermore, this could undermine the fiscal soundness of physician practices which could lead to access to care issues.

Additionally, the Medical Society has significant concern about the requirement that all physicians who order, refer, or prescribe services or prescriptions to enroll with MassHealth, even if as a non-billing provider, by September 1, 2016.  While the Medical Society appreciates that this requirement is filtered down from the Affordable Care Act, September 1 is an unreasonable timeframe, especially since regulations are still not final as of the end of July. We strongly urge the delay of this requirement until early 2017 to provide physicians and administrative staff time to process the applications of all of these physicians. A short time period before the promulgation final regulations and September 1, 2016 is not sufficient time to get over 20,000 physicians enrolled in MassHealth. Additionally, physicians are under other administrative requirements, including enrollment and training to use the new MassPAT system. Extending the MassHealth provider enrollment date into 2017 is a more reasonable timeline and would help avoid this currently unfair and untenable proposed requirement.     

The Medical Society appreciates the opportunity to comment on these very significant proposed changes. Given the little public discourse on this topic, we welcome the opportunity to discuss the matters in more detail.






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