Today, the Centers for Medicare & Medicaid Services (CMS) updated its Medicare claims hold guidance to Medicare Administrative Contractors, which is copied below. The AMA had been communicating with CMS behind the scenes and urging the agency to clarify its guidance in light of significant confusion about which claims are being paid during the ongoing federal government shutdown.

“CMS instructed all Medicare Administrative Contractors (MACs) to lift the claims hold and process claims with dates of service of October 1, 2025, and later for certain services impacted by select expired Medicare legislative payment provisions passed under the Full-Year Continuing Appropriations and Extensions Act, 2025 (Pub. L. 119-4, Mar. 15, 2025). This includes claims paid under the Medicare Physician Fee Schedule, ground ambulance transport claims, and Federally Qualified Health Center (FQHC) claims. This includes telehealth claims that CMS can confirm are definitively for behavioral and mental health services. CMS has directed all MACs to continue to temporarily hold claims for other telehealth services (i.e. those that CMS cannot confirm are definitively for behavioral and mental health services) and for acute Hospital Care at Home claims.

Beginning October 1, 2025, for services that are not behavioral health services, many of the statutory limitations on payment for Medicare telehealth services that were, in response to the COVID-19 Public Health Emergency, lifted, and subsequently extended, through legislation again took effect. These include prohibition of many services provided to beneficiaries in their homes and outside of rural areas, and hospice recertifications that require a face-to-face encounter. In the absence of Congressional action, practitioners who choose to perform telehealth services that are not payable by Medicare on or after October 1, 2025, may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage (ABN). Further information on use of the ABN, including ABN forms and form instructions can be found here: https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-abn. Practitioners should monitor Congressional action and may choose to hold claims associated with telehealth services that are currently not payable by Medicare in the absence of Congressional action. For further information: https://www.cms.gov/medicare/coverage/telehealth.

CMS notes that the Bipartisan Budget Act of 2018 (Pub. L. 115-123, Feb. 9, 2018), which added section 1899(l) to the Social Security Act, allows clinicians in applicable Medicare Shared Savings Program Accountable Care Organizations (ACOs) to provide and receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restrictions and in the beneficiary’s home. Separate from requirements to participate in the Medicare Shared Savings Program, there is no special application or approval process for applicable ACOs or their ACO participants or ACO providers/suppliers to offer these covered telehealth services. Clinicians in applicable ACOs can furnish and receive payment for covered telehealth services under these special telehealth flexibilities. For clinicians in applicable ACOs, telehealth claims that CMS can confirm are definitively for behavioral and mental health services will be paid. At this time, claims for some telehealth services will continue to be held. For more information, including information on to which ACOs these flexibilities apply: https://www.cms.gov/files/document/shared-savings-program-telehealth-fact-sheet.pdf (PDF).”

The Centers for Medicare & Medicare Services (CMS) has released Merit-based Incentive Payment System (MIPS) payment adjustment information for the 2024 performance period/2026 MIPS payment year. Physicians 2024 MIPS final score determines the MIPS payment adjustment physicians will receive in 2026. A positive, negative, or neutral payment adjustment will be applied to the Medicare paid amount for covered professional services furnished in 2026. The AMA encourages physicians to review their final score as soon as possible as the deadline to file a Targeted Review is only open until November 14, 2025.

The AMA has sought clarification from CMS and they are still accepting and reviewing Targeted Reviews during the government shutdown. However, some decisions may be delayed due to the need for broader CMS staff review, and some staff are furloughed. There are no plans currently to extend the targeted review period.

For more information, please see the email blast from CMS below:

Now Available: 2026 MIPS Payment Adjustment Information

The Centers for Medicare & Medicare Services (CMS) has released Merit-based Incentive Payment System (MIPS) payment adjustment information for the 2024 performance period/2026 MIPS payment year.

• Your 2024 MIPS final score determines the MIPS payment adjustment you’ll receive in 2026.
• A positive, negative, or neutral payment adjustment will be applied to the Medicare paid amount for covered professional services furnished in 2026.

Access Your MIPS Payment Adjustment

Sign in to the Quality Payment Program (QPP) website using the same credentials that allowed you to submit your 2024 MIPS data and check your 2024 MIPS final score. Refer to the QPP Access User Guide (ZIP, 4MB) for more information.

Click “View Feedback” on the home page and select your organization (Practice, Alternative Payment Model (APM) Entity, Virtual Group).

• Practice representatives can access individual, subgroup, and group performance feedback (final scores and payment adjustments).
• APM Entity representatives can access APM Entity-level performance feedback (final scores and payment adjustments).
• Virtual group representatives can access virtual group-level performance feedback (final scores and payment adjustments).
• Third party representatives can’t access final feedback or payment adjustment information.

If you don’t have a HARP account or QPP role, please refer to the Register for a HARP Account (re: HARP account) and Connect to an Organization (re: QPP role) documents in the QPP Access User Guide and start the process now.

Medicare Shared Savings Program Accountable Care Organizations (ACOs)

Medicare Shared Savings Program ACOs are encouraged to identify at least one individual within your ACO who can obtain a HARP account with the Security Official role; additional individuals may request the Staff User role. ACO individuals can create and manage their HARP account and QPP access in the ACO Management System (ACO-MS).

Contact your ACO to find out how you can obtain a HARP account via ACO-MS. If you have any questions, please contact the ACO Information Center at SharedSavingsProgram@cms.hhs.gov or 1-888-734-6433 (Option 1).

• REMINDER: Representatives of Shared Savings Program ACO Participant Taxpayer Identification Numbers (TINs) and practices with clinicians receiving their APM Entity’s final score won’t be able to access the APM Entity’s performance feedback unless they’ve been granted the “staff user” QPP role for the APM Entity.

Payment Adjustment and Performance Feedback Resources:

• 2026 MIPS Payment Year Payment Adjustment User Guide – Reviews information about the calculation and application of MIPS payment adjustments, and answers frequently asked questions.
• 2024 MIPS Performance Feedback FAQs (PDF, 2MB) – Reviews the information available in performance feedback and how to access it. (We’re in the process of updating this resource with the Targeted Review deadline.)
• 2024 MIPS Performance Feedback Supplemental Reports Guide – Reviews the downloadable supplemental and patient-level reports for administrative claims quality and cost measures.
• 2024 Quality and Cost Benchmarks – Links to quality and cost measure benchmarks and supporting documentation. (Benchmarks determine measure scores.)

2024 Targeted Review Request Period Open Until November 14, 2025[1]

Beginning with the 2024 performance period/2026 MIPS payment year, the targeted review period closes 30 days following the release of MIPS payment adjustments (refer to 42 CFR 414.1385(a)(2)).

Who Can Request a Targeted Review?

Individual clinicians, groups, subgroups, virtual groups, APM Entities (including Shared Savings Program ACOs), designated support staff and authorized third party intermediaries may request that CMS review their MIPS final score and MIPS payment adjustment factor through a process called targeted review.

When to Request a Targeted Review

Review your MIPS performance feedback, including your MIPS final score and payment adjustment factor(s), on the Quality Payment Program website. If you believe there’s an error in the calculation of your MIPS final score or MIPS payment adjustment factor, you can request a targeted review now until November 14, 2025, at 8 p.m. ET. Be advised that our ability to respond to inquiries and resolve requests will be delayed in most cases until normal government operations resume. Examples of circumstances that could prompt a Targeted Review:

• Data were submitted under the wrong TIN or National Provider Identifier (NPI).
• You have Qualifying APM Participant (QP) status and shouldn’t receive a MIPS payment adjustment.
• Performance categories weren’t automatically reweighted even though you qualify for reweighting due to extreme and uncontrollable circumstances.

Note: This isn’t a comprehensive list of circumstances.

How to Request a Targeted Review

To access your MIPS final score, performance feedback and request a targeted review:

• Sign in using your HARP credentials (ACO-MS credentials for Shared Savings Program ACOs); these are the same credentials that allowed you to submit your 2024 MIPS data and check your 2024 final score.
• Click “Targeted Review” on the left-hand navigation.

CMS may require documentation to support a targeted review request, which varies by circumstance. A CMS representative will contact you about providing any specific documentation required.

• 2024 Targeted Review User Guide (PDF, 2MB) – Reviews the process for requesting a targeted review and examples for when you would or wouldn’t request a targeted review. (We’re in the process of updating this resource with the Targeted Review deadline.)

[1] Note: The federal government shutdown doesn’t affect your ability to submit a targeted review request by the above deadline, however it may affect our response time to resolve your request.

Claims Hold Update

In anticipation of possible Congressional action, CMS has instructed all Medicare Administrative Contractors (MACs) to continue to temporarily hold claims with dates of service of October 1, 2025, and later for services impacted by the expired Medicare legislative payment provisions passed under the Full-Year Continuing Appropriations and Extensions Act, 2025. This includes all claims paid under the Medicare Physician Fee Schedule, ground ambulance transport claims, and all Federally Qualified Health Center claims. Providers may continue to submit these claims, but payment will not be released until the hold is lifted.

Absent Congressional action, beginning October 1, 2025, many of the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 Public Health Emergency took effect again for services that are not behavioral health services. These include prohibition of many services provided to beneficiaries in their homes and outside of rural areas, and hospice recertifications that require a face-to-face encounter. In the absence of Congressional action, practitioners who choose to perform telehealth services that are not payable by Medicare on or after October 1, 2025, may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage (ABN). Further information on use of the ABN, including ABN forms and form instructions: https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-abn. Practitioners should monitor Congressional action and may choose to hold claims associated with telehealth services that are not payable by Medicare in the absence of Congressional action. For further information: https://www.cms.gov/medicare/coverage/telehealth.

CMS notes that the Bipartisan Budget Act of 2018 allows clinicians in applicable Medicare Shared Savings Program Accountable Care Organizations (ACOs) to provide and receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restriction and in the beneficiary’s home. There is no special application or approval process for applicable ACOs or their ACO participants or ACO providers/suppliers. Clinicians in applicable ACOs can furnish and receive payment for covered telehealth services under these special telehealth flexibilities. For more information: https://www.cms.gov/files/document/shared-savings-program-telehealth-fact-sheet.pdf (PDF).

Claims, Pricers & Codes

NCCI Alert: COVID-19 Vaccine Administration Edit Revision

Some providers may have 90480 claims denied when billed in conjunction with G0008, G0009, or G0010 as a result of a Procedure to Procedure edit released in the 2025 Quarter 4 National Correct Coding Initiative (NCCI) files. On October 14, 2025, CMS issued replacement NCCI files to remove this edit. Medicare Administrative Contractors (MACs) will reprocess claims with dates of service between July 1, 2025, and October 15, 2025, within approximately 30 business days, and Medicare providers don’t need to take any action. Alternatively, a provider may also choose to use the MAC appeals process if they don’t wish to wait for the automatic adjustment to occur, or they can wait to submit impacted claims until after CMS implements the change.

Access the Medicare replacement files.

The full message was posted by CMS here.

When certain legislative payment provisions (“extenders”) are scheduled to expire, CMS directs all Medicare Administrative Contractors (MACs) to implement a temporary claims hold. This standard practice is typically up to 10 business days and ensures that Medicare payments are accurate and consistent with statutory requirements. The hold prevents the need for reprocessing large volumes of claims should Congress act after the statutory expiration date and should have a minimal impact on providers due to the 14-day payment floor. Providers may continue to submit claims during this period, but payment will not be released until the hold is lifted.

Absent Congressional action, beginning October 1, 2025, many of the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 Public Health Emergency will take effect again for services that are not behavioral and mental health services. These include prohibition of many services provided to beneficiaries in their homes and outside of rural areas and hospice recertifications that require a face-to-face encounter. In some cases, these restrictions can impact requirements for meeting continued eligibility for other Medicare benefits. In the absence of Congressional action, practitioners who choose to perform telehealth services that are not payable by Medicare on or after October 1, 2025, may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage. Practitioners should monitor Congressional action and may choose to hold claims associated with telehealth services that are not payable by Medicare in the absence of Congressional action. Additionally, Medicare would not be able to pay some kinds of practitioners for telehealth services. For further information: https://www.cms.gov/medicare/coverage/telehealth.

CMS notes that the Bipartisan Budget Act of 2018 allows clinicians in applicable Medicare Shared Savings Program Accountable Care Organizations (ACOs) to provide and receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restriction and in the beneficiary’s home. There is no special application or approval process for applicable ACOs or their ACO participants or ACO providers/suppliers. Clinicians in applicable ACOs can provide these covered telehealth services and bill Medicare for the telehealth services that are permissible under Medicare rules during CY 2025, irrespective of further Congressional action. For more information: https://www.cms.gov/files/document/shared-savings-program-telehealth-fact-sheet.pdf. MACs will continue to perform all functions related to Medicare Fee-for-Service claims processing and payment.

The full message was posted by CMS here.

The AMA has long called for Congress to enact legislation that would: (1) permanently allow Medicare patients in every geographic area, not just patients in rural areas, to receive telehealth services by waiving the geographic restrictions in current law; and (2) permanently allow Medicare patients to receive telehealth services in their homes instead of having to go to a medical facility to receive telehealth from a distant site. To date, however, Congress has passed legislation that only temporarily waives these requirements. Most recently, in March 2025 Congress extended these telehealth flexibilities for a six-month period that ends Sept. 30, 2025.

Physicians who provide telehealth services to Medicare patients should be aware that if Congress is not able to pass legislation before Oct. 1, 2025, that extends government funding, then the current Medicare telehealth flexibilities will lapse. This means that telehealth services would be limited to rural areas as they were before the COVID public health emergency and that patients would not be able to receive telehealth services in their homes. In addition, the ability to provide audio-only services to Medicare patients would lapse, as would the Acute Hospital Care at Home program.

In past government shutdowns, whenever Congress passed legislation to reopen the government, it made the funding and policies retroactive to the effective date of the shutdown. Physician practices may want to consider adjusting their patient schedules for telehealth services, however, as neither the likelihood nor the duration of a shutdown are known.

ACRO Advocacy efforts are clearly demonstrated in the 2026 Physician Fee Schedule (PFS) and Hospital Outpatient Prospective Payment System (OPPS) Proposed Rules released earlier this week. Our work relating to a new radiation therapy code set and a site-neutral radiation therapy episode-based payment model are reflected in these regulations. CMS is proposing (1) to adopt the treatment delivery code set ACRO developed collaboratively with ASTRO (see appendix) and (2) a site-neutral payment mechanism for the new treatment delivery codes. 

However, ACRO would like to call attention to a possible catastrophic concern  in the rules: the placement of key radiation therapy delivery codes (77407 – radiation treatment delivery, intermediate; 77412 – radiation treatment delivery, complex) in inappropriate ambulatory payment classification (APC) groups under the OPPS rule. This error would negatively impact payments in the hospital outpatient setting and, due to the proposed site-neutral payment mechanism, will carry over to the PFS as well for potentially harmful effects in both settings. 

ACRO believes there are clear cost and clinical rationale for CMS to move these codes to more appropriate APCs. We urge you to help ACRO advocacy by weighing in directly with CMS to correct this error. In the coming weeks, please be on the lookout for a new grassroots platform that ACRO will be implementing to allow ACRO Members to contact CMS directly on this issue. 

In addition, ACRO Members can continue to help advance legislation to provide permanent stability to radiation oncology through legislative options such as the bipartisan Radiation Oncology Case Rate (ROCR) Act (S. 1031/HR. 2120). You can contact your Member of Congress to support ROCR by clicking here. 

ACRO will provide comments to CMS on these regulations later this summer and continue to keep its membership informed on these issues. 

To review the PFS rule, click here. To review the OPPS rule, click here.

A more detailed summary of the regulations follows and you can also visit acro.org for additional news. Our health policy team will be featuring a podcast to discuss these updates further in the near future.

KEY PROVISIONS IN THE 2026 PFS AND OPPS PROPOSED RULES  

This week, the Centers for Medicare & Medicaid Services (CMS) released the 2026 Physician Fee Schedule (PFS) and Hospital Outpatient Prospective Payment System (OPPS) Proposed Rules. A topline summary of provisions in the regulations is included below. 

2026 PFS Proposed Rule. Key policies included in the PFS rule include: 

• Conversion Factor
• The rule includes a 3.32% update to the PFS conversion factor for 2026 for non-APM providers. 
• Use of OPPS APCs to establish payment for Radiation Oncology Treatment Delivery, Superficial Radiation Treatment, and Proton Beam Treatment Delivery 
• CMS: “We are proposing to utilize the relationship between the proposed OPPS APC relative weights for APCs 5621, 5622, and 5623 to inform the valuation of PE-only CPT codes 77402, 77407, and 77412 when paid under the PFS.”
• CMS explicitly acknowledges the work done by ACRO and ASTRO with CMS and CMMI on an “episode-based alternative payment approach for radiation therapy services.” However, in pursuing this policy, ACRO believes CMS has inappropriately placed 77407 and 77412 in Ambulatory Payment Classification (APC) 5622 “Level 2 Radiation Therapy” in the OPPS Proposed Rule, which, by virtue of the new policy has negative carry-over effects to the PFS Proposed Rule. Based on cost and clinical data, ACRO will be advocating for the more appropriate placement of (1) 77407 in APC 5623 and (2) 77412 in APC 5624. 
• Updates to the Indirect Practice Expense (PE) Methodology 
• CMS: “We are proposing to reduce the portion of the facility PE RVUs allocated based on work RVUs to half the amount allocated to non-facility PE RVUs beginning in CY 2026.”
• As it relates to non-treatment delivery codes, this policy, in conjunction with the conversion factor update, results in the first generally positive update for freestanding radiation oncology providers in the last several years. 
• No Use of AMA Physician Practice Information Survey (PPIS) Data
• CMS: “Due to overarching concerns with the data … and our previously described policy goal to balance PFS payment stability and predictability with incorporating new data through routine updates to the MEI, we reiterate that we are not proposing to implement the PE/HR data or cost shares from the AMA’s survey data at this time, and are proposing instead to maintain the current PE/HR data and cost shares for CY 2026 PFS ratesetting.”
• ACRO-commissioned analyses found that the use of AMA PPIS data would have resulted in cuts of 18% or more for key treatment delivery codes. 
• Maintenance of 77427, Radiation tx management 5x, on the Telehealth List
• CMS proposes maintaining 77427 on the telehealth list for 2026. 
• As ACRO noted in its comment to the 2025 PFS Proposed Rule, face-to-face engagement between radiation oncologists, clinical treatment teams, and patients undergoing treatment is the most appropriate way to manage care. ACRO continues to believe that the use of telehealth for the face-to-face portion of radiation treatment management is no longer necessary now that the COVID-19 Public Health Emergency has concluded.

2026 OPPS Proposed Rule. Key policies included in the OPPS rule include: 

• Conversion Factor
• The rule includes a 2.4% update to the OPPS conversion factor for 2026. 
• Treatment Delivery Codes
• As noted above, ACRO is concerned about the inappropriate placement of 77407 and 77412 in APC 5622 “Level 2 Radiation Therapy” and will be advocating for the more appropriate placement of (1) 77407 in APC 5623 and (2) 77412 in APC 5624. 
• Other Key Radiation Oncology Codes
• In general, other key radiation oncology codes would see a 5% update relative to last year.

************

APPENDIX

Following last year's House Ways and Means Committee Hearing on the Collapse of Private Practice, the new Congress and the Administration are actively considering policies to reform the Medicare Physician Fee Schedule (PFS) to save independent physicians, private practice and office-based interventional care. In 2025, Medicare PFS reimbursement rates fall below the cost of providing care for more than 300 office-based interventional services. While efforts to address the Medicare PFS inflation update (i.e. the “conversion factor”) help, they aren't sufficient to address practice expense reimbursement shortfalls that have led to the collapse of private practice.

OBFA needs physicians to meet members of Congress in their local office. Set up a meeting here.

However, two promising bills (H.R. 10136 and H.R. 8404 / S. 4330) were introduced in the last Congress that respectively would remove certain high-cost supplies and equipment from the PFS in order to stabilize practice expense reimbursement for private practice. Together, these bills would stabilize services provided by independent physicians by establishing new payment models separate from the traditional Physician Fee Schedule — which was established in 1992 to reimburse for “physician fees,” not the substantial costs of supplies and equipment essential to modern medical practice. These bills would help save independent physicians across specialties, including Interventional Cardiology, Interventional Radiology, Urology, Nephrology, Pain Management, Radiation Oncology, Venous Care, and Vascular Surgery.

Your Voice Matters! Congress needs to hear directly from physicians about how these issues impact patient care in their districts and states. The OBFA team is ready to help connect you with your Representatives and Senators.

Take Action Now: Complete our brief form to have a member of our advocacy team help arrange a conversation with your Member of Congress in their local office. Your experience and perspective are invaluable in this fight to protect independent medical practices. Members want to hear stories from their home turf. 

The future of private practice and office-based interventional care hangs in the balance. Please don't wait—make your voice heard today!

Best regards, The OBFA Team

P.S. The time to act is now. Fill out our form today to help protect your practice and your patients' access to care.

ACRO is aggressively advocating to the Hill for a reversal of these PFS cuts in end-of-year Medicare legislation. As part of these efforts, ACRO is highlighting the fact that, for many independent physician practices, providing services under the PFS simply is no longer a viable option.  In 2024, according to Medicare’s own data, for at least 195 office-based interventions included in the Medicare Physician Fee Schedule – including radiation treatment delivery services – Medicare reimbursement no longer even covers the direct costs of providing such services. ACRO’s preliminary review of the 2025 PFS Proposed Rule has found that the number of non-viable services in the freestanding setting would grow by 50% to 300 non-viable services under the proposed regulation for 2025.

In order to address this problem and help advance fundamental PFS reform, Congress must remove certain high-cost equipment and supplies from the PFS, which effectively no longer covers many of the procedures which utilize such equipment and supplies.

ACRO will provide comments to CMS on these regulations later this summer and continue to keep its membership apprised of efforts to engage CMS and the Hill directly on these issues. 

To review the PFS rule, please click here.

To review the OPPS rule, please click here.

Please also visit www.acro.org for additional news.  

The findings conveyed include the following:

1. Direct and general supervision have a role in safe, quality care delivery when used responsibly. 
2. Some degree of flexibility at the discretion of the Radiation Oncologist is warranted in all sites of service. 
3. Certain treatments demand direct supervision at each session, while other treatments may only require direct supervision at the initiation of therapy.
4. Supervision requirements with reasonable exceptions should be unrelated to site of service and geographic location.  
5. Variations in supervision requirements based on advances in technology (e.g. “virtual direct supervision”) should be considered after further review in the future. 

At the end of 2023, ACRO performed the most robust nationwide survey of which we are aware, conducted over five months with participation from over 500 Radiation Oncologists in all practice settings and representing every state across the USA. The study, entitled, “Consensus on Payment Model Reform amongst Radiation Oncologists: The Radiation Oncology Payment Reform Survey” was authored by Dr. Joseph Wilding and colleagues, and presented at the 2024 ACRO Summit with the following key finding: 

• 69% of practicing U.S. Radiation Oncologists agree or strongly agree with site-neutral direct supervision requirements with limited exceptions. This finding reflected general agreement across the community and included responses from Radiation Oncologists in academic hospitals and veterans’ healthcare centers as well as hospital-based and freestanding sites-of-service. 

ACRO most recently conducted a second survey to gather additional feedback directly from its members. With 142 respondents, the key findings from the survey are as follows:

• 94% of ACRO Members surveyed believe Radiation Oncologists are the only healthcare providers comprehensively trained in treatment and management of radiation therapy patients.
• 64% of respondents believe direct supervision should be the standard across sites-of service at the initiation of radiation therapy.
• 86% of respondents indicated general supervision should be allowed at the discretion of the Radiation Oncologist, after the initiation of radiation therapy.
  
  

We are grateful for this feedback from the Radiation Oncology community. An informed and thoughtful approach to these complex issues is essential. This feedback will be incorporated into an updated consensus statement to be released by ACRO in the coming days.

Sincerely,

Tarita Thomas, MD, PhD, MBA, FACRO

Chair, ACRO Government Relations & Economics Committee

Dwight E. Heron, MD, MBA, FACRO, FACR, FASTRO

ACRO President

Medicare payments for radiation therapy services have been cut by 23% since 2013, threatening patient access to cancer care in communities across the country, with further cuts likely in coming years. ACRO, ACR, ASTRO and ASCO are committed to working together to ensure that cost effective, high value cancer care services are available for Medicare beneficiaries and all patients, while positioning the specialty for innovative breakthroughs in cancer treatment for future generations. The organizations' leaders believe that payment reform is an essential path forward for the future of the specialty. Broad Congressional interest in radiation oncology and Medicare physician payment reform provide a robust backdrop for potentially transformative action this year.

ACRO President Dwight Heron, MD, MBA, FACRO, FACR, FASTRO, said, “As four of the largest groups representing innovative and comprehensive cancer care, our coalition will leverage its wealth of expertise across the spectrum of health policy and economics to ensure the practice of radiation oncology remains sustainable in both community and hospital-based settings to the benefit of cancer patients for many years to come.”

ACR Board of Chancellors Chair Jacqueline A. Bello, MD, FACR, said, "The American College of Radiology is continually working to advance and maintain a health care delivery and payment structure that enables those with cancer to access lifesaving-and-quality-of-life-improving radiation oncology care in their communities. On behalf of our many radiation oncologist members and the patients we serve, the ACR is proud to work with ASTRO, ACRO and ASCO to move this important effort forward."

ASTRO Chair Jeff M. Michalski, MD, MBA, FASTRO, added, “ASTRO welcomes this partnership with ACRO, ACR and ASCO knowing that as a united discipline, we can achieve lasting reform for radiation oncologists and our patients.”

ASCO Board Chair, Everett Vokes, MD, FASCO, said, “The Association for Clinical Oncology supports collaboration across the cancer community and with policymakers toward needed payment reform that supports patient access to high-quality, equitable cancer care.”

ASTRO's Radiation Oncology Case Rate program (ROCR) seeks to address inadequacies of the current payment system. The societies are seeking input from their members and other stakeholders on payment reform, as they ask policymakers to address the urgent threat facing cancer treatment access. They are committed to supporting radiation oncology professionals, both in hospital and freestanding office settings, to secure fair, stable reimbursement. Payment reform in radiation oncology also must address disparities faced by patients in rural and underserved communities.

The groups’ leaders expressed confidence that their partnership will ensure continued access close to home to compassionate, technologically advanced, life-saving treatments for patients diagnosed with cancer. They also expressed a commitment to this important advocacy initiative to protect and enhance access to radiation therapy services for patients today and tomorrow.

One of the pieces of legislation highlighted at the hearing is H.R. 3674, the Providing Relief and Stability for Medicare Patients Act of 2023. Introduced by Reps. Bilirakis (R-FL), Cardenas (DCA), Murphy (R-NC) and Davis (D-IL) this legislation addresses the needs of specialty physicians practicing in community-based office settings that have been disproportionately impacted by CMS’ proposed changes within the fee schedule. Specifically, the clinical labor update policy, finalized in the CY2022 MPFS Final Rule, recognized the need for increased salary rates for all types of clinical labor (e.g., nurses and technologists), but, due to the budget neutrality constraints in the Medicare Physician Fee Schedule, decreased reimbursement rates for those services with high supply and equipment costs when performed in a community-based office setting. H.R. 3674 would provide critical relief for office-based specialists by increasing the non-facility/office-based practice expense relative value units negatively impacted by CMS’ clinical labor policy for the next two years.

The CLC is a strong supporter of H.R. 3674, and its member organizations are dedicated to facilitating advancement of the bill. “The impact of these cuts is real for physicians who care for Medicare beneficiaries in a community-based, office setting, and will increasingly result in diminished access to care for Medicare patients seeking a variety of critical services in their neighborhood,” said Dr. Megan Tracci, Chair of the Society for Vascular Surgery’s Advocacy Council. “H.R. 3674 is a critical step to provide desperately needed stability for those most impacted by the clinical labor update policy.”

Dr. Bob Tahara, President of the Outpatient Endovascular and Interventional Society added, “Office based specialty care is a critical service outside of the hospital setting. These specialists provide a wide range of services to patients with end-stage renal disease, eye disease, fibroids, as well as limb salvage and venous ulcer needs. Maintaining the office setting is critical for patient access and patients receiving care in a timelier manner.”

“For at least a decade, office-based specialty centers have been closing, resulting in a significant loss of access in rural and underserved areas. Enactment of H.R. 3674 is a critical bridge to ensuring that patients with cancer and other life-threatening diseases can continue to receive timely access to care as Congress continues to work on broader reform to the Physician Fee Schedule,” said Dr. Dwight Heron, President of the American College of Radiation Oncology.

The CLC appreciates the E/C Heath Subcommittee’s efforts to highlight this important legislation and looks forward to working together to ensure it is included in any year-end legislative package.

###

Alliance of Wound Care Stakeholders
American Association of Clinical Urologists
American College of Cardiology
American College of Radiation Oncology
American College of Radiology
American College of Surgeons
American Society for Radiation Oncology
American Society of Diagnostic and Interventional Nephrology
American Society of Nephrology
American Urological Association
American Vein & Lymphatic Society
American Venous Forum
Association of Freestanding Radiation Oncology Centers
CardioVascular Coalition
Dialysis Vascular Access Coalition
Free From Fibroids Foundation
Large Urology Group Practice Association
Outpatient Endovascular and Interventional Society
Renal Physicians Association
Society for Cardiovascular Angiography and Interventions
Society for Vascular Surgery
Society of Interventional Radiology
The US Oncology Network
United Specialists for Patient Access

The Clinical Labor Coalition is a group of national medical organizations, representing a broad range of physicians, health professionals and practice managers who care for Medicare beneficiaries in a community-based, office setting.

Contact:
Megan Marcinko 
Grant Herring

ACRO assisted in scheduling virtual meetings with members of Congress from each participating member's state and provided talking points to help make the meetings impactful. Approximately 60 physicians participated and met with members of Congress including Reps. Rick Allen, Gus Bilirakis, Ed Case, John Joyce, Darin LaHood, and John Rutherford as well as Senior Policy Advisors and Legislative Aides and Correspondents for dozens of others.

Here's a look at some of the points covered during these discussions:

• PFS payments = Conversion Factor * Relative Value Units (RVUs)
• The “conversion factor” is the inflation update that grows the entire “PFS pie” of Medicare spending. H.R. 2474 (AMA bill) supports “growing the pie” by implementing a permanent inflation update to the PFS.
• RVUs determine how money is distributed within that pie. H.R. 3674 is needed to stop those hit hardest by ongoing RVU cuts: office-based specialists.
• The 2022 PFS “clinical labor cuts” contained the most recent round of RVU cuts across specialties and in areas where there are significant health equity concerns. These cuts are more than 20% in some cases and occur through 2025. These cuts also are continuing to cause higher Medicare costs and higher Medicare beneficiary coinsurance.
• Ongoing cuts to office-based specialists also are a catalyst for consolidation with physician owned practices experiencing an 11% decrease over the last decade as they have been acquired by hospitals.
• A broad group of stakeholders including the American College of Cardiology, American College of Radiology, American Society of Nephrology, American Urological Association, and more agree that the ongoing office-based specialty cuts must be addressed.

You can still make a difference, even if you weren't able to participate in the Virtual Hill Day! Click here to contact your Member of Congress and ask them to support H.R. 3674 so we can secure additional cosponsors.

You can also reach out to ACRO Executive Director Fraser Cobbe for more information on getting involved.

Article by Michelle Stein:

Device makers are again urging lawmakers to provide relief from Medicare clinical labor policies that reduce reimbursement for office-based specialists that use high-tech medical equipment, warning that acting on physician fee schedule conversion factor cuts without looking at changes to the clinical labor policies won’t do enough to help in-office specialists and could lead to shifts in care to hospitals or other facilities.

“While the need for overall PFS reform rightfully has received significant attention in recent years, the disproportionate, negative impact on office-based specialty care has not,” the Advanced Medical Technology Association, Medical Device Manufacturers Association and Medical Imaging and Technology Alliance say in a letter to House and Senate leadership on Monday (Aug. 14).

“The most recent office-based specialty cuts (so-called ‘clinical labor policy’ cuts stemming from the 2022 PFS) currently are being phased in through 2025 and continue to cause terrible damage to the ability of office-based specialists to provide badly needed care,” they add.

The device makers have long been a proponent of mitigating the impact of CMS’ changes to clinical labor policy, which were finalized as part of the 2022 physician fee schedule along with a four-year transition period to ease into the cuts that mostly affect specialists. However, mitigation of the clinical labor cuts has been left out of packages where Congress included some relief for cuts to the conversion factor despite pushes from device makers and specialists.

The proposed 2024 physician fee schedule includes an overall 3.3% cut to the conversion factor as well as the third year of clinical labor cuts to office-based specialty relative value units that United Specialists for Patient Access says cuts some specialists by another 3%.

“As a result, certain office-based specialists will again be cut by another 6 - 7% in 2024 alone,” USPA’s website says.

The device makers say the cuts are leading to consolidation and warn they could feed into a shift from procedures performed in a physician’s office to a facility. Even if lawmakers step in to once again mitigate the conversion factor cuts -- a move some lobbyists don’t believe is guaranteed but could be part of discussions this fall -- that won’t be enough, the device makers say.

“Left unaddressed, these cuts could eliminate the physician office as a viable setting of care for many procedures and reduce treatment options for Medicare beneficiaries. At a minimum, the reductions will lead to a shifting of procedures from the office setting, which is more accessible and clinically appropriate for many beneficiaries, to hospital outpatient departments and ambulatory surgery centers,” the letter says.

“We believe that it is essential for Congress to enact H.R. 3674 in the near term and, over the long term, work with stakeholders to address a fundamental asymmetry in the PFS that disproportionately, negatively impacts office-based specialty providers,” the device makers say.

The Providing Relief and Stability for Medicare Patients Act of 2023, H.R. 3674, would provide two years of targeted relief for specialty care practices through an increase to the non-facility practice expense relative value units (PE RVUs) for services performed in an office-based setting that require the use of high-tech medical devices or pieces of medical equipment. This relief is targeted at services that were most negatively impacted by the clinical labor policy, the device makers note.

The bill would also require the Government Accountability Office to analyze site-of-service migration, consolidation, and increased Medicare beneficiary cost-sharing in addition to coming up with recommendations. The bill was introduced in June by Rep. Gus Bilirakis (R-FL), Tony Cárdenas (D-CA), Greg Murphy (R-NC) and Danny Davis (D-IL). -- Michelle M. Stein (mstein@iwpnews.com)

The bill was introduced Friday, May 26, by Representatives Gus Bilirakis, Greg Murphy, Tony Cardenas, and Danny Davis. This critical legislation mitigates cuts to office-based specialists for a targeted group of services for two years, thereby helping to avoid significant disruptions in patient access to care while overall concerns regarding the future of Medicare physician payments are addressed. ACRO is pleased to stand with all these organizations in support of this important legislation.

Click here to read the letter of support sent to the Representatives on Friday.

Click here to review the bill.

See the full alert from the Government Relations and Economics Committee.

SEE THE LETTER

News release:

WASHINGTON, D.C. and PLYMOUTH MEETING, PA —February 28,2022—Nearly 100 cancer organizations representing patients, providers and researchers sent a letter to the president and congressional leadership in support of funding the Cancer Moonshot initiative. The letter details the urgent need for funding especially in light of delayed screenings, treatments and research caused by the COVID-19 pandemic. It also makes clear the unique opportunity to accelerate the pace of discovery with additional resources.

“The Moonshot initiative’s goals of cutting the cancer death rate in half through prevention, early detection, innovation, and addressing inequities is laudable, timely, and achievable, but only with the allocation of adequate funding to support these initiatives,” the letter states.

It notes that more than 9.5 million people have missed cancer screenings because of the pandemic, including dramatic drops in the number of cervical, colorectal, breast, prostate, and lung cancer screenings and that, “a reignited Cancer Moonshot is timely to encourage and support the significant effort required to address those who have missed these important screenings.”

It also highlights the importance of creating the Advanced Research Project Agency for Health (ARPA-H) to accelerate cancer research and innovations in treatment, along with measures to increase human papillomavirus (HPV) vaccination and improve the nation’s nutrition and increase physical activity.

“We enthusiastically support this commitment to ‘end cancer as we know it’ and are prepared to work with bipartisan lawmakers to enact public policies that will achieve this goal,” said Robert W. Carlson, MD, Chief Executive Officer, National Comprehensive Cancer Network® (NCCN®), one of the organizations coordinating this outreach. “Improving equitable prevention, early detection, and treatment, will help us continue to make progress against one of the leading causes of death in the United States and worldwide.”

“A bold goal requires bold action, and we are eager to help achieve the Cancer Moonshot’s full potential,” said Lisa Lacasse, president of the American Cancer Society Cancer Action Network. “Cancer affects everyone, but it doesn’t affect everyone equally and there is significant progress to be made to ensure everyone has a fair and just opportunity to prevent, detect, treat and survive cancer. We look forward to working with the administration and Congress to pass proven public health policies that bring us all closer to a healthier future with less death and suffering from this disease.”

Read the letter.

NCCN and ACS CAN previously teamed up to share the message that “Cancer Won’t Wait and Neither Should You” to encourage recommended cancer screenings that dropped dramatically during the COVID-19 pandemic. President Biden echoed this concern while announcing the reignited Cancer Moonshot initiative, noting that more than 9.5 million people have missed cancer screenings because of the pandemic and recent studies have found a dramatic decrease in the number of cervical, colorectal, breast, prostate, and lung cancer screenings. Learn more about the urgent need to resume routine cancer screening, and the latest expert guidance on when to do so, at NCCN.org/resume-screening.

# # #

About the National Comprehensive Cancer Network

The National Comprehensive Cancer Network® (NCCN®) is a not-for-profit alliance of leading cancer centers devoted to patient care, research, and education. NCCN is dedicated to improving and facilitating quality, effective, equitable, and accessible cancer care so all patients can live better lives. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) provide transparent, evidence-based, expert consensus recommendations for cancer treatment, prevention, and supportive services; they are the recognized standard for clinical direction and policy in cancer management and the most thorough and frequently-updated clinical practice guidelines available in any area of medicine. The NCCN Guidelines for Patients® provide expert cancer treatment information to inform and empower patients and caregivers, through support from the NCCN Foundation®. NCCN also advances continuing education, global initiatives, policy, and research collaboration and publication in oncology. Visit NCCN.org for more information and follow NCCN on Facebook @NCCNorg, Instagram @NCCNorg, and Twitter @NCCN.

About ACS CAN at 20

The American Cancer Society Cancer Action Network (ACS CAN) makes cancer a top priority for policymakers at every level of government. ACS CAN empowers volunteers across the country to make their voices heard to influence evidence-based public policy change that saves lives. We believe everyone should have a fair and just opportunity to prevent, find, treat, and survive cancer. Since 2001, as the American Cancer Society’s nonprofit, nonpartisan advocacy affiliate, ACS CAN has successfully advocated for billions of dollars in cancer research funding, expanded access to quality affordable health care, and made workplaces, including restaurants and bars, smoke-free. As we mark our 20th anniversary, we’re more determined than ever to stand together with our volunteers and save more lives from cancer. Join the fight by visiting www.fightcancer.org.

On March 25, the Senate voted 90-2 to pass an agreement reached by Leaders Schumer and McConnell to extend the 2 percent Medicare sequester moratorium that expires on April 1. The bipartisan legislation, offered as an amendment by Senators Shaheen and Collins, would provide a nine-month extension of the moratorium, through December 31. It also contains some technical corrections related to rural health clinics and disproportionate share hospitals.

The House of Representatives passed different legislation earlier that would both extend the moratorium through the end of the pandemic and eliminate an additional 4 percent Medicare sequester scheduled to take effect on January 1, which was required by PayGo rules to offset part of the cost of passing the American Rescue Plan COVID-19/stimulus package. Consequently, the House will need to pass the Senate language when it returns from its Easter recess in mid-April. The House is expected to vote favorably, and the Centers for Medicare & Medicaid Services is expected to hold off on processing April claims until then to avoid making reduced payments.

Physician and other stakeholder groups affected by the upcoming 4% sequester scheduled for January 1 expect legislation to be considered later in the year to waive those cuts.

HHS Secretary Azar has extended the COVID-19 Public Health Emergency (PHE) declaration effective Jan. 21, 2021 for an additional 90 days. This means that all of the telehealth and other waivers and flexibilities that have been implemented during the PHE will remain in effect until at least April 21, 2021.

In addition, as indicated in the summary and impact table distributed earlier this week, the Consolidated Appropriations Act that was signed into law on Dec. 27, 2020, included provisions that offset most of the 10.2% budget neutrality adjustment that had been slated to take effect for Medicare-covered services provided as of Jan. 1, 2021. CMS has now confirmed that it is implementing the following provisions of this legislation and that there will be no delay in claims processing for 2021 services; that is, claims will be paid on time at the correct 2021 rates that reflect this legislation.

Message from CMS:

On December 27, the Consolidated Appropriations Act, 2021 modified the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS):

• Provided a 3.75% increase in MPFS payments for CY 2021
• Suspended the 2% payment adjustment (sequestration) through March 31, 2021
• Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023
• Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024

CMS has recalculated the MPFS payment rates and conversion factor to reflect these changes. The revised MPFS conversion factor for CY 2021 is 34.8931. The revised payment rates are available in the Downloads section of the CY 2021 Physician Fee Schedule final rule (CMS-1734-F) webpage.