Update from the Physician Payment Policy Workgroup (3P)

Richard W. Waguespack, MD, Coordinator for Socioeconomic Affairs, and Michael Setzen, MD, Coordinator for Practice Affairs, Co-chairs of 3P; Jean Brereton, MBA, senior director, Research, Quality Improvement and Health Policy; Jenna Kappel, MPH, MA, Director, Health Policy; Joe Cody, MA, Health Policy analyst; and Harrison Peery, Health Policy analyst. The Physician Payment Policy Workgroup (3P), co-chaired by Richard W. Waguespack, MD, and Michael Setzen, MD, is the senior advisory body to Academy leadership and staff on issues related to socioeconomic advocacy, regulatory activity, coding, or reimbursement, and practice services or management. 3P and the Health Policy staff were busy in 2011 with a continued high level of activity, constant e-mails and monthly calls, working tirelessly on behalf of all members. Below, we have highlighted some advocacy efforts (For the latest health policy updates, visit the “what’s new” page athttp://www.entnet.org/Practice/CMS-News.cfm). 3P’s Process for Private Payer Advocacy 3P developed a process for providing assistance to members dealing with private payers that may inappropriately deny or bundle a procedure or service you have furnished. The Academy cannot represent physician members individually on each issue with payers, so 3P recommends members contact their state otolaryngology society to resolve the issue at a state level. However, there are many resources available on the Academy’s website to assist members with individual issues, including appeal template letters, CPT for ENT articles, policy statements, and clinical indicators and guidelines. If the issue cannot be resolved at the state level, contact the Academy’s health policy department at healthpolicy@entnent.org and include all pertinent information including, a copy of the denial, the EOB (with HIPAA information redacted), setting of the procedure, or anything else that could help). 3P and staff will research the issue and decide whether to pursue advocacy with the payer. For more information, see http://www.entnet.org/Practice/Private-Payer-Resources.cfm. Examples of recent efforts to advocate on members’ behalf with private payers on a national level include: Discussing the balloon sinus ostial dilation reference medical policy with Blue Cross and Blue Shield Association’s (BCBSA) national medical director; and Commenting on United Health Group’s (UHG) direct-to-consumer hearing tests and aids and entering into dialogue with United Healthcare’s national medical director to discuss concerns. Look for updates in The News and on the website as 3P and Academy staff continue to work with United Healthcare on these concerns. (These issues are discussed in more detail in this issue on pages 33 for the BCBSA policy and 38 for UHG’s sale of hearing aids.) 3P would like to thank all of the committees and members who have provided input on these issues and others. We will continue to work on socioeconomic advocacy on behalf of the Academy and its members. Cahaba GBA Changes ‘Once in a Lifetime’ Policy  Cahaba Government Benefit Administrators®, LLC (Cahaba GBA) administers Medicare health insurance for the Centers for Medicare & Medicaid Services (CMS). A major win for Academy members is Cahaba GBA removing procedures from their “once in a lifetime” procedure list. After learning about the inclusion of several procedures on the list, the Academy sent a letter to Cahaba GBA on September 30 explaining why they should be taken off the list. Shortly after receiving the letter, Cahaba removed the procedures from the list. Resources Available to You  from 3P 3P has developed a number of resources available to members. During the annual meeting, 3P sponsored several miniseminars and presentations to educate members on issues that directly affect them. They included courses and seminars on the transition from ICD-9 to ICD-10 and how it affects you; the CMS Carrier Advisor Committee (CAC) and the Recovery Audit Contractor (RAC) process; and Academy Advocacy for Physician Payment. The sessions were highly successful and 3P looks forward to presenting them again in 2012. Along with the resources available during Annual Meeting, 3P also developed a webinar for AcademyU®, providing instruction on how to fill out a RUC survey to coincide with recent resurvey of CPT code 31231 Diagnostic nasal endoscopy. For more on these and other resources, see http://www.entnet.org/Practice/regulatorySocioAdvocacy.cfm.