This Week – November 10, 2018

This Week in Washington, D.C.

  • November 2018 Elections: Health Care a Major Ballot Issue for States and U.S. Congress
  • Tri-Society Alerts: GI Societies Applaud Long-Overdue Changes to ASC Annual Updates
  • GI Codes to Be Revalued after CMS Sides with Anthem; E/M Payment Changes Delayed

November 2018 Election Outlook:
Health Care a Major Ballot Issue for States and U.S. Congress


Last week, ACG updated members with a “November 2018 Election Outlook,” including what you may have missed during the ACG Practice Management Course. Among this year’s speakers at the Practice Management Course was former State Insurance Commissioner and Congressman, Earl Pomeroy, who served in the U.S. House of Representatives for 18 years, and was a member on the influential House Ways & Means Committee.  He provided an overview and outlook heading into the November 2018 elections, as well as some insight of the major health care public policy issues at play.  This talk proved to be a very insightful analysis after this week’s election results.  ACG thanks Drs. Ralph McKibbin and Jay Yepuri for leading a successful 2018 ACG Practice Management Course!

What did voters decide this week?

The results were a mixed bag in news for both Republicans and Democrats. Republicans gained 2 seats in the U.S. Senate (there are still 3 outstanding races that will likely help Republicans as well: AZ, FL, and MS). Democrats, however, took control over the U.S. House of Representatives, with significant net gains in districts across the country.

Democrats had significant wins in state governor races as well. Thirty-six governorships were on the ballot, including 26 held by Republicans. Democrats flipped governorships in Illinois, Maine, Michigan, New Mexico, Kansas, and Wisconsin. Republicans held governorships in Florida and Ohio. These results may essentially put to rest any additional efforts to repeal the Patient Protection and Affordable Care Act (ACA), passed in 2010.

As ACG has alerted previously membership, Medicaid expansion and the ACA continue to become major issues on state ballots. This holds true even for more Republican-leaning states. This year:


ACG also alerted members to other health care issues on state ballots, including:

What else is ACG watching?

ACG recently updated members on a lawsuit in Texas, where 20 state attorneys general have filed another suit on the ACA.  What is the background on this latest effort to repeal the ACA? As you may recall, in 2017, Congress effectively repealed the ACA’s “individual mandate” by zeroing-out the penalty for not having health insurance.  This was part of the law that revised income tax brackets for individuals and companies, known as the Tax Cuts and Jobs Act. This is significant, as part of the U.S. Supreme Court’s rationale for upholding the ACA in 2012 was that the individual mandate intrinsically links the other parts of the ACA.

These 20 state attorney generals contend that based on the Supreme Court’s logic above, the ACA should now be rendered unconstitutional.  The Justice Department echoed these arguments in June when it chose not to defend the ACA.  Please note that while the Tax Cuts and Jobs Act may have effectively eliminated the individual mandate, it only zeroed out the penalty beginning in 2019.

The 20 states include: Alabama, Arkansas, Arizona, Florida, Georgia, Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Nebraska, North Dakota, South Carolina, South Dakota, Tennessee, Texas, Utah, Wisconsin and West Virginia.

Will these states continue to be a part of the lawsuit, or will they begin to drop out as voters become more vocal about supporting the ACA, both at the federal and state level?

ACG will continue to update membership as the case moves through the courts.


Tri-Society Alerts:

GI Societies Applaud Long-Overdue Changes
to ASC Annual Updates

On November 2, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2019 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule. The administration continues to focus on decreasing administrative burden for the health care system.

Key changes to Medicare OPPS and ASC payment rates and policies for CY 2019 include:

ASC Payment Changes

  • ASC Inflationary Update: After more than a decade of advocacy by the GI societies and other stakeholder organizations, CMS finalized its proposal to update ASC payment rates using the hospital market basket rather than the consumer price index-urban (CPI-U) for 2019-2023. We applaud the change in the update but emphasize payment adequacy by site of service. CMS polices to set reimbursement rates across sites of service at the lowest reimbursed rate are misguided.
  • ASC Payment Update: CMS is updating ASC rates for CY 2019 by 2.1 percent. Click here to access proposed ASC payment rates for GI services.
  • Device-Intensive Policy: CMS modified the device-intensive criteria to allow procedures that involve single-use devices, regardless of whether they remain in the body after the conclusion of the procedure, to qualify as device-intensive. CMS also lowered the device-offset percentage used to identify device-intensive procedures from 40 percent to 30 percent, allowing procedures that use high-cost devices to be better recognized in the ASC setting.

Several device-intensive GI procedures benefit from this change, including:

OPPS Payment Changes & more: read the full alert here.


GI Codes to Be Revalued after CMS Sides with Anthem;
E/M Payment Changes Delayed

Late Thursday, November 1st,  the Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2019 Medicare Physician Fee Schedule (PFS) final rule, which includes several significant policy and payment changes that are expected to impact gastroenterologists beginning in CY 2021.

Most significantly, CMS will revalue colonoscopy with snare (45385) and EGD with biopsy (43239), which may impact these code families. In an unprecedented and disturbing development, both services were nominated as potentially misvalued by Anthem, a major player in the U.S. health insurance market. This is the first time a private payor has nominated CPT codes via the potentially misvalued codes process.

The Agency also finalized many of the proposed Evaluation and Management (E/M) coding, documentation and payment changes, but delayed their implementation until January 1, 2021. Stay tuned for a call to action on these issues.

ACG, AGA and ASGE are reviewing the final rule and will provide a detailed analysis. Read a topline summary of the GI codes revaluation and E/M components of the rule.

Review the fact sheets for the CY 2019 Physician Fee Schedule and the Quality Payment Program final rule.