In response to recent changes by the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS), beginning Jan. 1, 2026, we’re updating prior authorization requirements for certain radiology oncology CPT® and HCPCS codes.

This applies to UnitedHealthcare® Medicare Advantage Plans, UnitedHealthcare Community Plans, UnitedHealthcare commercial plans and UnitedHealthcare Individual Exchange plans.

Patients currently receiving radiation therapy

If prior authorization for IMRT, IGRT or Standard Radiation Therapy (2D/3D) was approved for treatment starting before Jan. 1, 2026, no new prior authorization request is needed. We’re working on a “grandfathering” effort to update all approved authorization for the termed IMRT, IGRT and Standard Radiation Therapy 2D/3D procedure codes with the updated radiation therapy procedure codes.

Patients needing radiation therapy on or after Jan. 1

For treatments starting on or after Jan. 1, 2026, submit prior authorization requests using the new AMA/CMS procedure codes for IMRT, IGRT and Standard Radiation Therapy (2D/3D) radiation therapy services.

On Jan. 1, 2026, the following codes will no longer require prior authorization:

On Jan. 1, 2026, the following procedure codes should be used for prior authorization when treating for oncologic and hematologic diagnoses:

You can review the coverage determination guidelines we use to facilitate our determinations for the radiation therapy services.

How to submit and manage prior authorizations

• Sign in to the UnitedHealthcare Provider Portal with your One Healthcare ID. If you don’t have a One Healthcare ID, register now.
• From the left-hand tabs, select Prior Authorizations & Notifications

This content is provided on behalf of Myriad Genetics as part of ACRO's Corporate Partnership Program: 

Radiation oncologists treating prostate cancer now have a more powerful tool in their precision medicine arsenal. Myriad Oncology has expanded its flagship MyRisk® Hereditary Cancer Test to include 15 additional clinically relevant genes, making it the only core germline test that includes 100% of the genes most strongly recommended by ASCO.¹

This update brings the total to 63 genes across 11+ cancer types, with the 15 new genes associated with breast, colorectal, endocrine, gastric, lung, ovarian, renal, and skin cancers.

Why It Matters for Radiation Oncologists

As clinical evidence continues to grow, germline mutations in genes like BRCA1, BRCA2, ATM, CHEK2, and others are increasingly influencing how radiation oncologists approach cancer care and leading oncology guidelines now position germline testing as a critical component of cancer care.

Knowing a patient’s mutation status can: • Guide treatment intensity • Predict radiation sensitivity and inform systemic therapy decisions (e.g., PARP inhibitors) • Guide surveillance and risk management strategies • Support family risk assessment and cascade testing

Streamlined Access for Oncology Workflows

The updated MyRisk Test is fully integrated with platforms like EPIC and OncoEMR, making it easy to order tests and review results within existing clinical workflows. Results are also accessible via paper requisitions and the Myriad patient portal.

Patient-First Services and Support

Myriad simplifies identifying patients who meet guideline-based germline testing criteria through the MyGeneHistory® online questionnaire and provides pre- and post-test education from board-certified Genetic Counselors at no additional cost.

Looking Ahead

As precision oncology continues to evolve, germline testing is becoming a cornerstone of personalized cancer care. Myriad’s expanded MyRisk Test ensures radiation oncologists have the most comprehensive, guideline-aligned genetic insights to help support evidence-based decisions across the care continuum.

Learn More: https://myriad.com/

¹Tung N, Ricker C, Messersmith H, et al. Selection of Germline Genetic Testing Panels in Patients With Cancer: ASCO Guideline. J Clin Oncol. 2024;42(21):2599-2615. 3. Internal product development data on file at Myriad Genetics, Inc. Last updated 2025.

The Centers for Medicare & Medicaid Services published an alert on fraud schemes that are increasingly targeting Medicare providers that involve bad actors impersonating CMS and sending phishing fax requests for medical records and documentation, falsely claiming to be part of a Medicare audit.

Phishing is an example of social engineering that attempts to trick you or someone else in your workplace into giving out sensitive information. Email phishing attacks are still a common occurrence, but we are hearing about more fraudulent fax requests being sent out to medical practices by bad actors.

CMS emphasized that it does not initiate audits by requesting medical records via fax. We urge physicians and practices to take steps to protect their data. If physicians receive a suspicious request, do not respond. CMS encourages you to work with your Medical Review Contractor if you receive a questionable or suspected fraudulent request to confirm if it is real.

Earlier this year, the CMS Innovation Center (CMMI) announced the Enhancing Oncology Model (EOM). EOM builds on insights from the Oncology Care Model (OCM) and intends to drive transformation in oncology care by enhancing the quality of care furnished to beneficiaries undergoing chemotherapy while reducing Medicare fee-for-service (FFS) spending. The application period for EOM closed on October 10, 2022. CMS is in the process of reviewing the submitted applications in advance of the model launch on July 1, 2023.

Today, the Centers for Medicare & Medicaid Services Innovation Center released two new resources to help EOM stakeholders understand EOM’s health equity strategy and the new Enhanced Service requirement, gradual implementation of electronic patient-reported outcomes (ePROs).

The following resources are now available on the EOM website:

• Health Equity Strategy Factsheet: This four-page factsheet describes key elements of EOM’s health equity strategy, including information on health-related social needs (HRSN) in the model and a review of data collection and reporting requirements in EOM.
• Implementing Electronic Patient-Reported Outcomes (ePROs) Factsheet: This two-page factsheet provides an overview of the benefits of ePROs, and information on the gradual implementation of ePROs requirements under EOM.

The EOM Team will continue to use your feedback to inform development of additional resources that prepare interested stakeholders for EOM’s launch, so we encourage you to continue to visit the EOM website and sign up for the EOM listserv to receive any updates.

For additional questions about EOM, please reach out to our support team at EOM@cms.hhs.gov, or call 1-888-734-6433, option 3. Please also visit the model website at innovation.cms.gov/innovation-models/enhancing-oncology-model for more information.

In April 2021, the Office of the National Coordinator for Health Information Technology’s (ONC) rules on information blocking went into effect. Information blocking is defined as practices that are likely to interfere with, prevent, or materially discourage the access, exchange, or use of electronic health information (EHI). Physicians, hospitals, electronic health record vendors, health information exchanges, and health information networks (also known as “Actors”), are all subject to ONC's regulations. Since April 2021, information blocking requirements have been focused on a narrow subset all EHI. However, starting October 6, 2022, ONC’s information blocking requirements shift to the entire set of EHI. After October 6, physicians and other Actors will be responsible for the access, exchange, or use of the full EHI requirement. The attached document provides an overview of the information blocking regulations, EHI definition, and recommendations for physicians to prepare for the upcoming deadline.

Late this afternoon, the Centers for Medicare and Medicaid Services (CMS) circulated the following note. American Medical Association staff will evaluate the information and compare notes with our Federation colleagues.

New Rules

Most notably, today the Departments released final rules that account for the two district court rulings on the NSA and take into account comments from stakeholders to the interim final rules released last year. The rulemaking is narrow in scope, addressing specific issues related to disclosures by plans and issuers about the QPA and guidance for certified IDR entities on information to consider when they make payment determinations.

The new rule can be found here: https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act

New FAQs

The Departments also issued a new set of FAQs providing guidance on several NSA requirements including how the law’s protections apply to no-network and closed-network plans, requirements related to disclosures, and the calculation of the qualifying payment amount, among other things. The new FAQs can be found here: https://www.cms.gov/files/document/faqs-part-55.pdf

Status Update on IDR and additional guidance

Finally, the Departments also released a brief status update on the federal IDR process. In short, many more disputes have been submitted to the federal IDR process than were initially anticipated. Additionally, certified IDR entities are conducting significant work determining whether a dispute is eligible for the federal process.

To help address this, on Tuesday we posted a new page on the CMS No Surprises Act website detailing some common mistakes and helpful tips for parties initiating IDR disputes. Our objective here is to help initiating parties get the certified IDR entities and non-initiating parties as much info on the front end as possible to help correctly determine eligibility and move disputes through the process. This also includes detailed technical guidance for the certified IDR entities on moving disputes through the process. While the guidance is technically for IDR entities, it’s publicly posted, and we think it could be helpful for disputing parties to keep in mind when they’re submitting information related to disputes.

We also rolled out some new functionality in the portal for initiating disputes. There’s now a dispute-level upload button which allows initiating parties to upload supporting documents to their disputes at initiation. We’re hopeful this will prevent delays in processing disputes by making sure that certified IDR entities have immediate access to documents like documents associated with the initial payment or notice of denial of payment (e.g., remittance advice or an explanation of benefits), notices of open negotiation initiation, extension requests, etc.

As part of our ongoing efforts to address alternative payment models for cancer care, the following is an announcement distributed yesterday from CMS announcing The Enhancing Oncology Model (EOM). The ACRO Government Relations and Economics Committee (GREC) will be reviewing this program and looks forward to sharing further information with ACRO Membership in the future.

Dwight E. Heron, MD, MBA, FACRO, FACR
ACRO Vice President & ACRO Government Relations & Economics Committee Co-Chair

Announcement from the Centers for Medicare & Medicaid Services (CMS):

Today, the Centers for Medicare & Medicaid Services (CMS) Innovation Center is happy to announce the new, voluntary Enhancing Oncology Model (“EOM”). The Biden-Harris Administration’s Cancer Moonshot aims to improve the experience of people and their families living with cancer. EOM is aligned with the Biden-Harris Administration’s effort to meet its Cancer Moonshot goal of improving the experience of people living with cancer by supporting and learning from cancer patients, caregivers, and cancer survivors, addressing inequities, and providing the right treatments to the right patients.

“No one should have to battle cancer without access to high quality, coordinated care,” said HHS Secretary Xavier Becerra. “With this new Innovation Center model for oncology care, we are delivering on President Biden’s call to action to mobilize every option to address cancer, and creating a system of care that supports all patients and their families. We will continue to do all we can to make access to this care equitable and end cancer as we know it.”

“There are stark inequities in the ability of people with cancer across race, gender, region, and resources to access cancer screening, diagnostics and treatment,” said Chiquita Brooks-LaSure, CMS Administrator. “CMS is working to advance President Biden’s Cancer Moonshot goals in ways that help Medicare cancer patients better navigate a challenging and often overwhelming journey. We believe the Enhancing Oncology Model will incentivize participating oncology practices – including those in rural and underserved areas – to improve the provision of high quality, coordinated care that addresses patients’ social needs and improves patient and caregiver support.”

EOM also aligns with the CMS Innovation Center Strategic Objectives of driving accountable care, advancing health equity, and improving access by addressing affordability. The goal of EOM is to drive transformation in oncology care by preserving and enhancing the quality of care furnished to beneficiaries undergoing treatment for cancer while reducing Medicare program spending. EOM aims to improve quality and reduce costs through payment incentives and required participant redesign activities. Oncology practices that participate in EOM will take on financial and performance accountability for episodes of care surrounding systemic chemotherapy administration to patients with common cancer types.

EOM builds on the successes and lessons learned of the Oncology Care Model (OCM) and feedback from the oncology community, including, but not limited to OCM participants, patient advocacy groups, oncology professional associations, and others. EOM focuses on value-based, patient-centered care for cancer patients with a specific focus on health equity. CMS encourages oncology practices caring for underserved beneficiaries to apply. EOM will include screening for health-related social needs (HRSNs), introduce data reports on expenditure and utilization patterns of their patient population to help health care professionals identify and address health disparities, and offer an additional payment for the provision of Enhanced Services to patients who are dually eligible for Medicare and Medicaid that is not included in the total cost of care responsibility. EOM participants will ask patients to routinely report their symptoms in order to encourage better communication and a more proactive care response, and EOM participants will be required to submit plans outlining how they will promote health equity.

EOM is set to launch on July 1, 2023, and will be a five-year model test.

The EOM Request for Applications is available now on the EOM website at https://innovation.cms.gov/innovation-models/enhancing-oncology-model.

To apply to participate in EOM, applicants must submit their applications at https://app.innovation.cms.gov/EOM. The application period for EOM is currently open. All EOM applications must be submitted by 11:59 pm Eastern Daylight Time on September 30, 2022. CMS may not review applications submitted after the deadline.

There will be an EOM Overview Webinar on Thursday, June 30, 2022 at 3:00-4:30 PM EST. Register to attend here.

For more information, please reference the EOM website at https://innovation.cms.gov/innovation-models/enhancing-oncology-model.

Reminder: MIPS 2021 Data Submission is Open through March 31

The data submission period for Merit-based Incentive Payment System (MIPS) eligible clinicians who participated in the 2021 performance year of the Quality Payment Program (QPP) is open. Data can be submitted and updated until 8:00 p.m. ET on March 31, 2022. CMS recently added new 2021 Data Submission Demonstration Videos on its YouTube channel to support submission.

How to Submit Your 2021 MIPS Data

Clinicians will follow the steps outlined below to submit their data:

1. Go to the Quality Payment Program webpage.
2. Sign in using your QPP access credentials (see below for directions).
3. Submit your MIPS data for the 2021 performance year or review the data reported on your behalf by a third party.

How to Sign In to the Quality Payment Program Data Submission System

To sign in and submit data, clinicians will need to register in the HCQIS Authorization Roles and Profile (HARP) system. For clinicians who need help enrolling with HARP, please refer to the Quality Payment Program Access User Guide.

How to Confirm Eligibility

Clinicians who are not sure if they are eligible to participate in the Quality Payment Program can check their final eligibility status using the QPP Participation Status Tool. Clinicians and groups that are opt-in eligible will need to make an election before they can submit data. (No election is required for those who don’t want to participate in MIPS.)

2021 Extreme and Uncontrollable Circumstances (EUC) Application Period Reopened

CMS alsoreopenedthe MIPS EUC application for groups, virtual groups, and Alternative Payment Model (APM) Entities that need to cite COVID-19 as the triggering event through March 31, 2022, at 8 p.m. ET. Note: Because of the automatic EUC policy, individual clinicians don’t need to submit an application.

For More Information

To learn more about how to submit data, please review the following resources available on the QPP Resource Library:

• 2021 Data Submission User Guide
• 2021 APP Data Submission User Guide
• 2021 MIPS Opt-In and Voluntary Reporting Election Guide
• 2021 Data Submission FAQs
• NEW!  2021 Data Submission Demonstration Videos Playlist:
  1. Reporting as a Group Under the APM Performance Pathway (APP)
  2. Reporting as a Medicare Shared Savings Program ACO Under the APM Performance Pathway (APP)
  3. Manual Attestation for Promoting Interoperability Performance Category of MIPS
  4. Connecting to an Organization as a Practice for MIPS
  5. Connecting to an Organization APM Entity

You can contact the Quality Payment Program at 1-866-288-8292, Monday through Friday, 8 a.m. - 8 p.m. ET or by e-mail at: QPP@cms.hhs.gov. To receive assistance more quickly, please consider calling during non-peak hours— before 10 a.m. and after 2 p.m. ET.

• Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.
  
  

Reminder: CMS Recently Reopened the MIPS Extreme and Uncontrollable Circumstances Application for the 2021 MIPS Performance Year in Response to COVID-19

CMS continues to offer flexibilities to provide relief to clinicians responding to the 2019 Coronavirus (COVID-19) public health emergency (PHE). We applied the Merit-based Incentive Payment System (MIPS) automatic extreme and uncontrollable circumstances (EUC) policy to all individual MIPS eligible clinicians for the 2021 performance period.

Recently, we’ve also reopened the MIPS EUC application for groups, virtual groups, and Alternative Payment Model (APM) Entities through March 31, 2022, at 8 p.m. ET. (Because of the automatic EUC policy, you don’t need to submit an application for individual clinicians.) Please note that applications received between now and March 31, 2022, won’t override previously submitted data for groups and virtual groups.

MIPS EUC applications citing COVID-19 as the triggering event can be submitted until Thursday, March 31, 2022, at 8 p.m. ET.

This listserv will review what the MIPS EUC application extension means for:

• Groups and virtual groups that haven’t submitted data.
• Groups and virtual groups that have submitted data.
• APM Entities.

Groups and virtual groups that haven’t submitted data:

• Groups:  You don’t need to take any further action if you’re unable to submit data for the 2021 performance period. Group participation is optional, and your individual MIPS eligible clinicians qualify for the MIPS automatic EUC policy. They’ll have all 4 performance categories reweighted to 0% and receive a neutral payment adjustment for the 2023 MIPS payment year unless 1) they submit data in 2 or more performance categories as individuals, or 2) the practice reports as a group, by submitting data for one or more performance category.
• Virtual Groups:  If you’re unable to submit data for the 2021 performance period, you must submit a MIPS EUC application for all 4 performance categories by the March 31, 2022, deadline.

Groups and virtual groups that have submitted data.

• Groups and virtual groups that have submitted data for a single performance category:
  • If you’re unable to complete data submission for other performance categories, you can submit a MIPS EUC application to request reweighting in the remaining 3 performance categories.
  • This includes small practices that were automatically scored as a group on Medicare Part B claims measures submitted throughout the 2021 performance period.
  • If you don’t submit a MIPS EUC application, your group will be scored in all performance categories unless you’re eligible for reweighting in one or more performance categories.
  • If your application is approved and no additional data is submitted at the group level (or available for scoring, such as the automatic improvement activities credit awarded to groups with clinicians participating in an APM), your MIPS eligible clinicians will receive a neutral payment adjustment for the 2023 MIPS payment year.
• Groups and virtual groups that have submitted data for 2 or 3 performance categories:
  • Your MIPS eligible clinicians will receive a MIPS final score and MIPS payment adjustment for the 2023 MIPS payment year.
  • You can’t submit an application to override previously submitted data  but you can submit an application to request reweighting of performance categories for which you haven’t submitted data.

APM Entities (Includes Shared Savings Program Accountable Care Organizations (ACOs))

Official representatives of APM Entities participating in MIPS, including Shared Savings Program ACOs, can submit a MIPS EUC application on behalf of all MIPS eligible clinicians in the APM Entity for the 2021 performance year. If approved, all of the MIPS eligible clinicians in the APM Entity will receive a neutral MIPS payment adjustment in the 2023 MIPS payment year. (Applications must be submitted by an official representative of the APM Entity, and not by a participant in the APM.)

There are some differences from our existing MIPS EUC policy for individuals, groups, and virtual groups:

• APM Entities are required to request reweighting for all performance categories.
• More than 75% of the MIPS eligible clinicians in the APM Entity must be eligible for reweighting in the Promoting Interoperability performance category.
• Unlike MIPS EUC applications for individuals, groups and virtual groups, an APM Entity’s approved application for performance category weighting will override previously submitted data.

Additional Resources

• Quality Payment Program COVID-19 Response Factsheet (PDF)
• 2021 MIPS Extreme and Uncontrollable Circumstances Exception Application Guide
• 2021 Data Submission FAQs

For more information, please see the Quality Payment Program COVID-19 Response webpage of the QPP website. You can contact the Quality Payment program at 1-866-288-8292, Monday through Friday, 8 a.m. - 8 p.m. ET or by e-mail at: QPP@cms.hhs.gov. To receive assistance more quickly, please   consider calling during non-peak hours— before 10 a.m. and after 2 p.m. ET.

• Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.

In light of the recent Supreme Court ruling on January 13, 2022, employee vaccination requirements from the Centers for Medicare & Medicaid Services (CMS) now apply to certain Medicare or Medicaid providers and suppliers. Please see below for new and updated tools and resources developed by CMS to help you navigate and determine if these vaccine requirements apply to you. These materials are all available from the CMS Current Emergencies page:

Guidance memo (cms.gov) – This memo provides guidance for assessing and maintaining compliance with this new regulatory requirement for certain Medicare and Medicaid providers and suppliers.

CMS Omnibus COVID-19 Health Care Staff Vaccination Requirements FAQ (PDF cms.gov) (PDF) – These FAQs have been updated to explain the recent ruling and how it impacts employee vaccination requirements.

IFC-6 Vaccination Requirements Infographic (cms.gov) (PDF) – This infographic visually shows the types of providers and suppliers the vaccine requirement applies to, how the requirement can be met, and associated requirement enforcement actions.

Vaccine Requirement Implementation Timeline (cms.gov) (PDF) – This infographic illustrates the phases of the vaccination rule implementation, state-by-state, and their associated deadlines. Note that the phased deadlines vary by state.

Vaccine Requirement Decision Tree (cms.gov) (PDF) – This handy decision tree visually explains the steps in determining to which providers and suppliers the vaccine requirement applies.

The U.S. Department of Labor’s Occupational Safety and Health Administration is withdrawing the vaccination and testing emergency temporary standard issued on Nov. 5, 2021, to protect unvaccinated employees of large employers with 100 or more employees from workplace exposure to coronavirus. The withdrawal is effective January 26, 2022.

Although OSHA is withdrawing the vaccination and testing ETS as an enforceable emergency temporary standard, the agency is not withdrawing the ETS as a proposed rule. The agency is prioritizing its resources to focus on finalizing a permanent COVID-19 Healthcare Standard. OSHA strongly encourages vaccination of workers against the continuing dangers posed by COVID-19 in the workplace.

CMS Vaccination Requirement for Healthcare Workers

While the US Supreme Court struck down OSHA’s COVID-19 vaccination requirement for employers with 100+ employees, the Court ruled that the CMS Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule may be implemented. CMS updated its FAQ document for this rule on January 20, 2022: External FAQ IFC-6 - 1.21.22 (cms.gov)

This document is thorough and should provide answers to most of your questions.

FAQ Highlights

Who must comply?

The vaccination requirement does not apply to Physician Group Practices. It does apply to Ambulatory Surgery Centers enrolled in Medicare and/or Medicaid.

The requirement does not apply to therapy services rendered within a Physician Group Practice.

The requirement does apply to all hospitals enrolled in Medicare and/or Medicaid so those facilities will require all physicians, Physician Assistants and Nurse Practitioners who render services in their facilities to comply even if they are not employed by the facility.

Deadlines

Phase 1 deadline for FL, PA, MD, DE: January 27, 2022
Phase 2 deadline for FL, PA, MD, DE: February 28, 2022

Phase 1 deadline for GA, SC, Kansas, Missouri: February 14, 2022
Phase 2 deadline for GA, SC, Kansas, Missouri: March 15, 2022

Phase 1: Staff must have received at least the first dose of a primary series or a single dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its patients. 

Phase 2: Staff must complete the primary vaccination series (except for those who have been granted exemptions from the COVID-19 vaccine or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by CDC).

Boosters:

For the purposes of this Rule, booster doses are not currently needed for staff who have completed a COVID-19 primary vaccination series authorized or licensed by the FDA.

Documentation Plan:

Regulated facilities must implement a process or plan for documenting and tracking staff vaccinations. The Rule does not include testing requirements for unvaccinated staff.

Exemptions:

CMS requires facilities to allow for exemptions to staff with (as a reasonable accommodation for a disability or a sincerely held religious belief, observance, or practice and for medical reasons. Providers and suppliers should establish exceptions as a part of its policies and procedures and in alignment with Federal law… no exemption should be provided to any staff for whom it is not legally required or who requests an exemption solely to evade vaccination. Refer to the Updated CMS FAQ Document for more information: View document

The Centers for Medicare & Medicaid Services (CMS) continues to provide relief where possible to clinicians responding to the 2019 Coronavirus (COVID-19) public health emergency (PHE). We’re applying the Merit-based Incentive Payment System (MIPS) automatic extreme and uncontrollable circumstances (EUC) policy to ALL individually eligible MIPS eligible clinicians for the 2021 performance year (PY). Please note that this announcement is for PY2021 only.

The automatic EUC policy only applies to MIPS eligible clinicians who are eligible to participate in MIPS as individuals. The automatic EUC policy doesn’t apply to groups, virtual groups, or Alternative Payment Model (APM) Entities.

MIPS eligible clinicians who are eligible to participate in MIPS as individuals

You don’t need to take any action to have the automatic EUC policy applied to you. You’ll be automatically identified and will have all 4 MIPS performance categories reweighted to 0% and receive a neutral payment adjustment for the 2023 MIPS payment year unless you 1) submit data in 2 or more performance categories, or 2) have a higher final score from group or APM Entity participation.

Small practices reporting Medicare Part B claims measures

Under current policies, we automatically calculate a quality score from Medicare Part B claims measures at the individual and group level.

• Clinicians in small practices that report Medicare Part B claims measures who are only eligible to participate in MIPS as part of a group aren’t covered by the automatic EUC policy and will receive the group’s final score. (To identify these clinicians, sign in to qpp.cms.gov, navigate to the “Eligibility & Reporting” page and click “View Clinician Eligibility”. Clinicians who are only eligible to participate as part of a group will have a green check mark next to “Group”; there won’t be a green check mark next to “Individual”.)
• Some small practices may not be aware of the implications of their PY 2021 claims reporting due to some of the policies we introduced at the onset of the COVID-19 PHE.
• As a result, these small practices may wish to request performance category reweighting on behalf of the group through the PY2021 EUC Exception Application, citing COVID-19 as the triggering event.
• PY2021 EUC Exception Applications can be submitted by signing in to qpp.cms.gov and clicking Exception Applications on the left-hand navigation.

Groups

The automatic EUC policy doesn’t apply to groups. You don’t need to take any further action if you’re not able to submit data for the 2021 performance year. Group participation is optional (specific guidance for small practices noted above), and your individually eligible MIPS eligible clinicians qualify for the automatic EUC policy if you don’t report at the group-level on their behalf. (If you submit data at the group level on behalf of your MIPS eligible clinicians, the group will receive a MIPS final score based on the data submitted.) Your MIPS eligible clinicians will have all 4 performance categories reweighted to 0% and receive a neutral payment adjustment for the 2023 MIPS payment year unless 1) they submit data in 2 or more performance categories, or 2) they have a higher final score from group or APM Entity participation.

Virtual Groups

MIPS eligible clinicians in a virtual group will receive a payment adjustment based on the virtual group’s final score, even if no data is submitted. (When no data is submitted for the virtual group, the MIPS eligible clinicians in the virtual group could receive the maximum negative payment adjustment of -9% in the 2023 payment year.)

• If you’re unable to submit data for the 2021 performance year as a result of the ongoing COVID-19 PHE, you can submit a PY2021 EUC Exception Application on behalf of the virtual group, citing COVID-19, to request reweighting for all 4 performance categories.
• PY2021 EUC Exception Applications can be submitted by signing in to qpp.cms.gov and clicking Exception Applications on the left-hand navigation through December 31, 2021.

APM Entities

The automatic EUC policy doesn’t apply to APM Entities. You don’t need to take any action if you’re not able to submit data for the 2021 performance year. APM Entity participation is optional (specific guidance for small practices noted above), and your individually eligible MIPS eligible clinicians will have the automatic EUC policy applied to them if you don’t report at the APM-Entity level on their behalf. (If you submit data at the APM-Entity level on behalf of your MIPS eligible clinicians, the APM Entity will receive a MIPS final score based on data submitted.) Your MIPS eligible clinicians will have all 4 performance categories reweighted to 0% and receive a neutral payment adjustment for the 2023 MIPS payment year unless 1) they submit data in 2 or more performance categories, or 2) they have a higher final score from group or APM Entity participation.

If your APM Entity would like to request performance category reweighting for the 2021 performance year, you must submit an EUC application.

• PY2021 EUC Exception Applications can be submitted by signing in to qpp.cms.gov and clicking Exception Applications on the left-hand navigation through December 31, 2021.

Medicare Shared Savings Program ACOs

The MIPS Automatic EUC policy doesn’t apply to Shared Savings Program Accountable Care Organizations (ACOs). ACOs can submit a PY2021 EUC Exception Application on behalf of its MIPS eligible clinicians if they are unable to report via the Alternative Payment Model (APM) Performance Pathway (APP). To submit a PY2021 EUC Exception Application, ACOs must demonstrate that greater than 75% of its MIPS eligible clinicians would be eligible for reweighting the Promoting Interoperability performance category. ACOs can submit PY2021 EUC Exception Applications by signing in to qpp.cms.gov and clicking Exception Applications on the left-hand navigation through December 31, 2021.

Note: The Shared Savings Program Quality EUC policy for determining shared savings and losses applies to all Shared Savings Program ACOs for performance year 2021. CMS considers all ACOs to be affected by the COVID-19 PHE and the Shared Savings Program EUC policy applies for PY2021. ACOs that are able to report quality data via the APP and meet MIPS data completeness and case minimum requirements will receive the higher of their ACO quality score or the 30th percentile MIPS quality performance category score. ACOs that are unable to report quality data via the APP and meet the MIPS quality data completeness and case minimum requirements, will have their quality score set equal to the 30th percentile MIPS quality performance category score.

Additional Resources

• 2021 MIPS Extreme and Uncontrollable Circumstances Application Guide
• Quality Payment Program COVID-19 Response Fact Sheet

For more information, please see the Quality Payment Program COVID-19 Response webpage on the QPP website. You can contact the Quality Payment program at 1-866-288-8292 (TRS: 711), Monday through Friday, 8AM-8PM ET or by e-mail at: QPP@cms.hhs.gov.

Disclaimer: The contents of this listserv do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This listserv is intended only to provide clarity to the public regarding existing policies under the law.

CMS has posted the presentation slides and a recording of the stakeholder call for your convenience.

To view the slides, click here. 

To view the video, click here.

In addition to the resources above, CMS has prepared a frequently asked questions document, available here.

The next stakeholder call will be held on: Wednesday, November 10 from 3:30 – 4:30 PM EST

To register in advance, click here. 

After registering, you will receive a confirmation email containing information about joining the webinar.

*Please note: they can only accommodate 10,000 participants so register early to guarantee your participation.*

The Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), has announced a new application cycle for $25.5 billion in COVID-19 provider funding (Phase 4). The application for the funds is open now, and will close on October 26, 2021 at 11:59 p.m. ET. Applicants will be able to apply for both Provider Relief Fund (PRF) Phase 4 and American Rescue Plan (ARP) Rural payments during the application process. In order to streamline the application process and minimize administrative burdens, providers will apply for both programs in a single application.

PRF Phase 4 is open to a broad range of providers with changes in operating revenues and expenses. ARP Rural is specifically available to providers who serve rural patients covered by Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). See a detailed list of eligible provider types here.

HHS recently hosted a briefing session to provide information about these upcoming funding opportunities – view the video here. HRSA will also host webinar sessions featuring guidance on how to navigate the application portal.

• Tuesday, October 5, 3:00 – 4:00 p.m. ET – register to attend
• Wednesday, October 13, 3:00 – 4:00 p.m. ET – register to attend
• Thursday, October 21, 3:00 – 4:00 p.m. ET – register to attend

Real time technical assistance is available by calling the Provider Support Line at (866) 569-3522, for TTY dial 711. Hours of operation are 8 a.m. to 10 p.m. CT, Monday through Friday.

The Centers for Medicare & Medicaid Services (CMS) is pleased to invite the public to attend its upcoming webinar titled Driving Quality in the US: How CMS Evaluates its Measure Portfolio. Quality measures are an important tool that CMS uses to assure quality healthcare for beneficiaries—but how does CMS make certain that the measures in its portfolio are effective? This webinar will walk audiences through CMS tools and processes, specifically the MMS Blueprint, Pre-rulemaking process, Quality Measure Index, and Impact Assessment, to evaluate the quality of its quality measures throughout the measure lifecycle. The webinar will also provide information about key quality measurement resources available to the public. The webinar will be offered twice in July:

• • • Tuesday, July 13, 2021, from 1:00 p.m. – 2:00 p.m., ET (Register here)
    • Wednesday, July 14, 2021, from 3:00 p.m. – 4:00 p.m., ET (Register here)

Please register in advance if you can attend, as space will be limited. We request that you please only register for an event if you plan to attend. We hope you can join us and look forward to your questions! For questions about the webinar, please contact MMSSupport@battelle.org.

Learn more:

• Homepage for OSHA Emergency Temporary Standard for the Health Care Industry
• Summary/Fact Sheet of Temporary Standards
• Full PDF of the new requirements

News articles:

• Kaiser Health News
• New York Times
• Washington Post

Today, the Centers for Medicare & Medicaid Services (CMS) announced that the 2020 MIPS Cost Performance Category will be reweighted to 0% of the final score even if eligible physicians or groups submitted 2020 data in other MIPS categories in light of the impact of the COVID-19 pandemic. For over a year, the AMA has been recommending that CMS zero out this category during the pandemic for several reasons, including concerns that decreases in patient visits and increases in the costs of caring for patients with COVID-19 could unfairly penalize physicians. We applaud CMS for holding physicians harmless from unfair evaluations in the MIPS Cost Performance Category as a result of the COVID-19 pandemic.

The AMA also strongly supports CMS’ decision to release the 2018 and 2019 cost measure benchmark files, which we will review closely to identify the target spending for those years, how the benchmarks capture any variations in spending, and whether the benchmarks are leading to fair and valid comparisons among physicians. Again, the AMA has been recommending to CMS for a while that the agency should publish the data.  In April, the AMA and 47 national medical specialty societies sent a letter urging CMS to immediately release the MIPS cost benchmarks to increase transparency in how the agency evaluates physician performance in the Cost Performance Category in MIPS and to allow physicians and other stakeholders to assess the measures for validity and opportunities to reduce spending. We anticipate this information will be informative for specialty societies that are engaged in the ongoing development of new episode-based cost measures and MIPS Value Pathways (MVPs).

The results of a study conducted by Weill Cornell Medicine that was sponsored by the AMA and the Physicians Foundation have now been published. Researchers conducted 30 in-depth, semi-structured interviews with physician leaders in small and medium internal medicine and general surgery practices and large multispecialty practices about their experiences participating in Medicare’s Merit-based Incentive Payment System (MIPS). An article published in the Journal of General Internal Medicine provides qualitative results of physicians’ experience with the program, while an article published in JAMA provides quantitative insights into the cost of participating in MIPS and MIPS APMs.

Among the interesting qualitative findings:

• MIPS is viewed as a continuation of previous programs and a precursor of future programs;
• Performance measures are more relevant to primary care practices than other specialties
• Leaders are conflicted on whether the program improves patient care
• Participation creates administrative burden, exacerbated by frequent programmatic changes
• Incentives are small relative to the effort
• External support for participation can be helpful

In terms of cost, researchers found:

• Annual cost of participation is about $12,000 per physician
• Annual time spent by clinicians and staff is about 200 hours per physician
• Costs per physician were predictably higher for smaller practices and for APM participants

• These funds are loans that are required to be repaid.
• Repayment begins one year from when the Medicare advance payment is received, rather than 120 days under the original terms.
• The per claim recoupment amount was reduced from 100% to 25% for the first 11 months, and then 50% for an additional six months.
• If there is an outstanding balance after the 17-month recoupment time frame, the Medicare Administrative Contractor (MAC) will issue a demand letter requiring repayment subject to an interest rate of 4%, a decrease from the original interest rate of 10.25%.
• Physicians may repay the Medicare advance payment in full at any time by contacting their MAC.

The AMA would like your feedback about recoupment of the Medicare advance payments. Please share your feedback by emailing AMA.Advocacy@ama-assn.org.

The new report “Changes in Medicare Physician Spending During the COVID-19 Pandemic” analyzed Medicare claims data exclusive to physician services and found spending dropped as much as 57% below expected pre-pandemic levels in April of 2020. Medicare spending on physician services partially recovered from the April low but was still 12% less than expected by the end of June 2020. During the first half of 2020, the cumulative estimated reduction in Medicare physician spending associated with the pandemic was $9.4 billion (19%). The report also provides estimates by state and specialty.

The cumulative reduction in MPFS spending for radiation oncology was 8%.

Attached is an initial guide provided by the American Medical Association (AMA) to the major provisions in the “No Surprises Act,” the surprise billing legislation that was included in the Consolidated Appropriations Act COVID-19 relief bill signed into law on December 27, 2020.

The No Surprises Act allows for price transparency, provider directories, and patient financial protections that impact health plans, physicians, facilities, and other non-MD/DO licensed health care professionals. The law goes into effect on January 1, 2022.

The intent of the law is not to preempt state surprise billing laws. However, there is some ambiguity in the statutory language that will require further clarification before and during the rulemaking process, including when the surprise billing protections apply to patients in self-funded ERISA plans.

The AMA will work with Federation members and other stakeholders to seek clarification to address these ambiguities and will revise this guide accordingly as new information becomes available.

New guidance from the AMA provides special coding advice during the COVID-19 public health emergency. One resource outlines coding scenarios designed to help health care professionals apply best coding practices. Be sure to check the AMA COVID-19 resource center to stay up to date and for additional resources.