This Week – November 8, 2014

This Week in Washington DC:

  1. Medicare Releases 2015 Physician Fee Schedule Payment and Facility Fees Rules
  2. November 2014 Elections: What does it mean for clinical GI?

2015 Medicare Payment Rule Good News: Revaluation of Colonoscopy Codes Delayed

The Centers for Medicare and Medicaid Services (CMS) on Friday, October 31st issued the final rule for physician reimbursement under Medicare for calendar year (CY) 2015. The agency delayed its valuation of lower GI codes until CY2016, as requested by the three GI societies’ presidents at a meeting with CMS Administrator Marilyn Tavenner, as well as in comments by more than 450 GI physicians to the agency this summer.

ACG, AGA and ASGE have been advocating on GI reimbursement issues together throughout the year. We will continue to work with CMS in 2015 as the agency determines the 2016 payment rates for GI procedures.

How Upper GI Codes Fared

In addition to urging delay to the colonoscopy family of codes, the three GI societies also worked with CMS throughout this year to reverse some of the drastic cuts to the upper GI services implemented in the 2014 Medicare payment rule. The GI societies are encouraged to learn that CMS mitigated some of these cuts in the 2015 final Medicare physician payment rule.

While we still have more work to do to recoup these cuts to the upper GI services, CMS’ reversal underscores the impact that the GI societies’ advocacy efforts overall had on the upper endoscopy codes as well.

The Details: Please click here to view the chart to review the 2015 Medicare payment rates for the top ten GI services compared to 2014 payment rates.

Positive Updates in 2015 Medicare Hospital Outpatient and ASC Facility Rates

Also on Friday, October 31st, CMS also released the final rule on the 2015 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Policy Changes and Payment Rates.

Overall, OPPS payments for GI services received a positive update for CY2015. The increase is based on the projected hospital market basket increase, minus multi-factor productivity and a 0.2 percentage point adjustment required by law, and includes other payment changes, such as increased estimated total outlier payments.

The Details: Please click here to view an HOPPS Analysis chart for 2015 and a list of 2015 HOPD facility rates for selected GI procedures compared to 2014.

ASC payments are annually updated for inflation by the percentage increase in the Consumer Price Index for all urban consumers (CPI-U). Our societies continue to urge CMS to align this annual update with the OPPS and are disappointed that CMS continues to use the CPI-U. However, for CY 2015, facility rates for selected GI codes did receive positive updates.

The Details: Please click here to view an ASC Payment Analysis chart for 2015 and a list of 2015 ASC facility rates for selected GI procedures compared to 2014.

November 2014 Elections: What does it mean for clinical GI?

On November 4, 2014 voters in the United States went to the polls to vote on 33 seats in the U.S. Senate and all 435 seats in the U.S. House of Representatives. Republicans took advantage of low voter turnout and President Obama’s low approval ratings and seized control of the U.S. Senate.  Republicans also bolstered their majority in the U.S. House.

Prior to the election, U.S. Senate Democrats controlled the majority with 53 seats, which included two independent Senators, to the Republicans’ 47 seats. Republicans picked up 7 seats, with two races still outstanding, resulting in a Republican majority of 52 seats to the Democrats’ 46 seats. The two races that remain outstanding, as of Friday, include Alaska (Republicans likely to pick up) and the Louisiana race, which will go to a runoff on December 6th (Sen. Mary Landrieu vs. Bill Cassidy, MD FACG).

Republicans also padded their majority in the House of Representatives, adding a net 13 seats as of Friday. Also as of Friday, the makeup of the U.S. House is 243 Republicans to 180 Democrats with 12 races outstanding.

How will the elections impact the GI clinician? Some federal legislatives issues include:

  • Repealing the ACA. Republicans have campaigned on full repeal of the ACA since 2010. While Republican House leaders have passed this measure before, Republicans in the U.S. Senate may now find a path to pass full repeal in the U.S. Senate. This will be vetoed by President Obama. Thus, full ACA repeal will be symbolic but it may be an opportunity for Republicans to claim they are delivering on campaign promises. Forcing President Obama to veto the any full-ACA repeal could be used in preparation for the 2016 elections as well.
  • Repealing parts of the ACA. Republicans will have the opportunity to pass narrower bills targeting specific issues in the ACA. These bills will also attract some Democratic support. The issues include: repealing the 2.3% excise tax on sales of medical devices that is passed on to facilities/purchasers, changing ACA employer coverage mandates such as the definition of “full time employees” (currently defined as 30 hours per week), repealing the ACA requirement that all individuals to purchase health insurance, and repealing the yet-to-be-appointed Independent Payment Advisory Board (IPAB).
  • SGR reform. Legislation that repeals the sustainable growth rate (SGR) and reforms Medicare reimbursement already has bi-partisan support. However, Congress has been unable to agree on the revenue-raising offsets in order to pass these bills. These “offsets” may be easier to find in a Republican controlled House and Senate.

It is also very important to note that ACG and your ACG Governor are closely monitoring the state elections results and potential impact to your practice. For example:

  • Newly elected governors and state legislatures. Will Pennsylvania’s newly elected Democratic Governor, Tom Wolf, scrap his predecessor’s plan to expand Medicaid and instead go with a more traditional Medicaid expansion route? Will this expansion include medical homes? Will Arkansas’s newly elected Republican Governor Asa Hutchinson scrap the plan to expand Medicaid rolls via private insurance, as crafted by outgoing Democratic Governor Mike Beebe? Will Arizona’s newly elected Republican Governor Doug Ducey continue with the outgoing Republican Governor Jan Brewer’s plan to expand Medicaid despite expected resistance from fellow Republicans in the state legislature? Will Ohio’s Republican Governor Jim Kaish push harder for Medicaid expansion now that he won reelection with 64% of the vote? What will that mean for GI providers in OH who, along with ACG and others, are currently opposing unwarranted cuts to Medicaid reimbursement for endoscopy procedures? What will newly elected Republican Governor Charlie Baker do in Massachusetts, the state where health reform was first implemented?
  • How will any federal changes to the ACA (individual mandate, employer mandate) impact the states’ decisions to expand their respective Medicaid programs, or authority to review insurer premium changes/coverage decisions?

Other state issues that were on the ballots:

  • California residents rejected a proposal to give the insurance commissioner the authority to reject changes in insurance rates for individuals and small markets.
  • California residents also rejected measures regulating physician conduct, such as drug and alcohol testing, as well as a proposal to increase medical malpractice damage awards.
  • South Dakota residents approved a measure to eliminate “narrow provider” networks in favor of “any willing provider” networks.
  • Arizona residents approved a measure that allows patients with terminal illnesses the opportunity to access unapproved therapies.
  • Louisiana residents approved a mechanism by which hospitals will be able to generate more federal Medicaid reimbursement.

Please stay tuned for further updates. Please also share and discuss your thoughts with fellow ACG members on the ACG GI Circle. To login and share your comments, go to and sign in as a member. Once you have done so, click here and then click the orange “Visit ACG GI Circle” button to be taken to the GI Circle site. If you have not yet activated your ACG GI Circle account, please email us at

Contact Brad Conway, VP Public Policy, with any questions or for more information.

Brad Conway