RheumWATCH Archives


Read the RheumWATCH archives on topics such as rheumatology advocacy, policy updates, insurance advocacy, and practice management.


Legislative Update—Issues Impacting Your Practice and Patience

Receive a PQRS Payment Penalty Letter? Review Process Open until Feb. 28

The PQRS informal review process is open for any eligible professional (EP) or group practice who believes that they have received an incorrect PQRS payment penalty letter from CMS for 2013. Providers can verify their information by entering their tax ID number and NPI into the CMS PQRS Look Up tool.

The Look Up tool is connected to files that access information in regard to whether an EP should have received a 2013 incentive, as well as whether they are subject to the 2015 payment adjustment. EPs who believe that they may have received a payment adjustment in error must file an informal appeal by Feb. 28, 2015.

EPs or group practices can request an informal review of their PQRS reporting performance through the Communication Support Page. Providers may request an informal review if they have received a notification in error from CMS indicating that they did not successfully participate in 2013 PQRS, if they believe that their PQRS payment amount was incorrect, or if their PQRS feedback report indicates that they did not earn the PQRS incentive payment when they believe that they should have. If you have questions or need assistance, please contact Maryam Gueye at mgueye@rheumatology.org.

How to Revalidate Your Medicare Provider Enrollment

Did you receive a revalidation request from your Medicare contractor? Once a revalidation request is received, you only have 60 days to respond. According to CMS, almost 300,000 Medicare physicians and other providers will need to revalidate their Medicare enrollment by May.

All providers who enrolled with Medicare prior to March 25, 2011 are required to revalidate their Medicare enrollment by submitting the appropriate CMS-855 Medicare enrollment form(s) to their Medicare contractor only after receiving a notification letter.

Revalidation Applications

You can revalidate your CMS-855 Medicare enrollment applications via Internet-based PECOS or the paper application process, which can be downloaded from the CMS website, along with the required supporting documentation applicable to you or your practice (see list below).

Required Documents

  • Provide a copy of Business Licenses or Certifications (if applicable)
  • Provide a copy of Final Adverse Legal Action Documentation and Resolution (if applicable)
  • Provide proof of application fee payment or hardship exception (if applicable)
  • Provide a diagram/flowchart in addition to completing Section 5
  • Provide a government responsibility letter (if Section 5 of the CMS-855 form identifies a government organization)
  • Provide an IRS determination letter (if registered with IRS as “non-profit")
  • Provide a CMS-588 Electronic Funds Transfer (EFT) form, including an original voided check or bank letter (individual providers that reassign all benefits to a group are not required to submit the CMS-588)

There are also educational tutorials on the PECOS website with step-by-step instructions on how to submit your revalidation application. To check the status of your application or to confirm receipt of submission, you may use the enrollment status lookup tool for both Internet-based PECOS submissions and paper applications.

For questions or additional information on revalidating your Medicare status, contact Antanya Chung at achung@rheumatology.org or 404-633-3777 x818.

Lawmakers Every Rheumatologist Should Know

Now that the 114th Congress is under way, new leaders and committee members have been selected for their roles. Leaders on just a few key committees will have tremendous influence on nearly every federal issue that is relevant to rheumatology. Do you live, practice, or have patients in these lawmakers’ districts?

Lawmakers on the Senate Health Education Labor and Pensions Committee (HELP) and the House Energy and Commerce Committee (E&C) will have jurisdiction in their respective chambers over all issues related to healthcare. Nearly every bill relevant to rheumatology will pass through these committees. The Senate Finance Committee and the House Ways and Means Committee are also pivotal because of their jurisdiction over CMS, Medicare and Medicaid.

The new lawmakers and leadership to know on these committees include:

Senator Lamar Alexander is the new Chairman of the Senate HELP Committee. Senator Alexander was elected from Tennessee in 2002 and has served on the HELP Committee since arriving in the Senate in 2003. His approach to healthcare reform includes allowing the purchase of insurance across state lines; permitting small businesses to join together to offer cheaper insurance to employees; limiting junk lawsuits against doctors; reducing waste, fraud and abuse; and expanding health savings accounts.

Senator Patty Murray is the new Ranking Member of the Senate HELP Committee. Senator Murray represents the state of Washington in Congress. She became the highest-ranking Democrat on the Committee after Senator Tom Harkin’s retirement last year. Senator Murray’s priorities include expanding quality access to healthcare, supporting research and technological advances, and addressing the shortage of healthcare workers, among other things.

Senator Bill Cassidy is a physician from Louisiana who was newly elected to the Senate in 2014 and selected to serve on the HELP Committee. Prior to arriving in the Senate, Dr. Cassidy was a U.S. Congressman, a faculty member at LSU Medical School and a co-founder of the Baton Rouge Community Clinic, which provided free care to working uninsured.

Senator Orrin Hatch is the new Chairman of the Senate Finance Committee. Senator Hatch represents the state of Utah in Congress. His priorities include strengthening Medicare, Medicaid and Social Security. He has led past initiatives to increase prescription drug coverage for seniors.

Congressman Frank Pallone is the new Ranking Member of the House Energy and Commerce Committee. Congressman Pallone was chosen by his caucus to serve in this role after Congressman Henry Waxman’s retirement. Congressman Pallone serves out of New Jersey’s 6th congressional district. He is an original author of the Affordable Care Act.

Congressman Joe Kennedy is serving his second term in congress from Massachusetts’ 4th district, and was recently appointed to the Energy and Commerce Committee. Congressman Kennedy is a strong supporter of the NIH and research for chronic conditions. He is focused on strengthening and streamlining our healthcare system to accommodate increasing demands of a larger and older population.

Congressman Paul Ryan is the new Chairman of the House Ways and Means Committee. Congressman Ryan serves in the House from Wisconsin’s 1st congressional district. In the last Congress, Congressman Ryan was Chairman of the Budget Committee, but elected to serve on the House Ways and Means Committee instead. Congressman Ryan is committed to strengthening Medicare as Chairman.

If you live, practice, or have patients in these lawmakers’ districts, please contact the ACR at advocacy@rheumatology.org for more information on how to get involved in local advocacy.

Message from the Government Affairs Chair

Will HarveyDear Advocates,

As anticipated, the early part of this year is heating up with lots of things going on related to some important issues. Of course I haven’t felt the heat up here in Boston. In fact, the first government update to give you is that a local New England district attorney has secured an arrest warrant against Mr. Phil the groundhog on the basis of fraud and public deception. I love it, but of course that’s not the only legal case that could have a profound impact on healthcare, so on to the updates.

ACA & Supreme Court Case

Oral arguments are set for March 4, and a decision is expected in the summer. As most of you probably know, this is a challenge to the federally run state exchanges that are part of the ACA. It is widely believed that if struck down, it would essentially gut the ACA and require another major overhaul of healthcare legislation to fix. If upheld, it again puts repeal or major reform out of reach while President Obama is still in office. The update here is that Republicans at the highest level have stated that they will be ready to introduce and pass a replacement to the ACA pending the court’s decision. The best template we have now is the newly updated Patient CARE Act, which is the likely blueprint. The ACR is in the process of dissecting this plan and formulating some opinions on its provisions related to our issues, and we look forward to updating you more on this in the near future. The very basic highlights include means-tested insurance subsidies via a tax break, reform of employer-based insurance, tort reform, interstate purchasing of insurance and price transparency. As I said, there is more analysis to come. See the summary >


Our interest: Still in passing a permanent repeal. Whether we like it or not, this is the best chance we have to move on to other issues we deeply care about. With that price tag over Congress’ head, they are less willing to tackle other things.

Roadblocks: Money. As predicted, the latest CBO score increased the price for full repeal up to around $172 billion. We have started to hear on the Senate side that the price tag is too steep to deal with right now and that a patch is likely, perhaps 9 months.

My take: We have also heard from very high-ranking Republican House leadership that they are committed to passing a permanent repeal by March that has a workable pay-for. My take, based on input from our lobbyists, is that it will be very hard for the House to accomplish that, but we are happy to be surprised. We will see in the coming weeks what transpires and what form a patch might take.


Our interest: Supporting any effort to ease the burden of ICD-10.

Roadblocks: There was a hearing on the subject this week in D.C. Despite the concerns still expressed by many provider groups, it became even more clear that there will be NO further delay. Chairmen Pitts and Upton have publically stated they will not support a delay.

My take: ICD-10 will absolutely happen on Oct. 1, 2015. I used to feel 75% certain and now I equate the chance of delay with the prevalence of ANA-negative lupus. So get ready. Still, the ACR continues to further our interest by pushing for more testing and for flexibility and leniency in the post go-live period to reduce the number of rejected claims. I can share with you an excerpt from a GAO report on ICD-10.

“CMS officials stated that the submission of valid ICD-10 codes is a requirement for payment; however, when the presence of a specific diagnosis code is not required for payment then the claim would be paid even if a more appropriate ICD-10 code should have been used on the claim. For example, CMS officials told us that, because there are many reasons why an individual would need to go in for an office visit, office visits do not require the claim to include specific ICD-10 codes; therefore, as long as a claim for an office visit includes a valid ICD-10 code, it would be paid. Additionally, CMS officials indicated that, absent indications of potential fraud or intent to purposefully bill incorrectly, CMS will not instruct its contractors to audit claims specifically to verify that the most appropriate ICD-10 code was used. However, audits will continue to occur and could identify ICD-10 codes included erroneously on claims which could lead to claims denials, according to CMS officials.”

This sounds good, but we will continue to push to see not only that this notion is codified in CMS rule-making, but also that assurances are gained that the contractors and private marketplace will follow suit.


Out interest: Removing discriminatory barriers to accessing essential treatments for our patients.

Roadblocks: We had a wonderful hearing on the matter in the last Congress, but our bill was not voted on. PATA will be reintroduced on Feb. 24, 2015, and the ACR will attend a Congressional Briefing on the matter that day. The roadblocks remain the insurers who want pharma to be held responsible for rising costs. We also need a Senate sponsor, but we hope to have positive news on that front in the coming weeks.

My take: If the insurance companies are worried enough to actively start opposing this, we must be on to something! I think we will get introduction in both houses this year. That will prompt some serious effort by the insurance industry and the most likely result will be some high-level closed-door meetings with insurance, pharma and Congress to duke it out. We’ll keep our ear to the ground on that. If we have bicameral introduction and actually get insurance and pharmacy to the table, it will be a successful year.


Our interest: Reform Meaningful Use and other reporting programs to decrease the reporting and financial burden on our members.

Roadblocks: While CMS had granted some extra hardship exemptions for 2014, 2015 was set to be a full year reporting period. Vendors have simply not given us products that are ready for prime time in this regard and through no fault of our own, many providers will struggle to meet Stage 2. CMS had previously indicated that there would be no changes to 2015.

Great news: The ACR, working with a coalition, had been supporting the Flex-IT Act, which would have changed 2015 to a 90-day reporting window, making it easier for members to meet Stage 2 as well as giving us and software vendors time to upgrade or change systems. CMS announced this week that they will enact the provisions of this bill administratively. 2015 will be a 90-day reporting window year, with full details to come very soon. This is a big win for the ACR and its membership, but there is still much to do to reduce burdensome reporting.

States of the Union

This is quickly shaping up to be a very active year for state legislation. In cooperation with the Affiliate Society Council and CORC, we are tracking a large number of issues. Of greatest volume currently is biosimilar legislation at the state level. We are pushing hard to require provider notification AND limit interchange to biosimilars, which pass the much higher bar of being designated as interchangeable by the FDA. Some of you may have heard that a biosimilar adalimumab did well in a Phase III trial. Of note, at this point the company is planning to apply as a biosimilar, not an interchangeable biosimilar. We expect pharmacies, insurers and state law to abide by FDA recommendations and not interchange this biosimilar if it gets approved without the interchangeability label. There is also much work going on regarding step therapy, network adequacy and many other issues at the state level.


Many of you read Howie’s impassioned plea. I repeat it and encourage all supporters to renew your commitment NOW. We have lots of work to do. And while you’re at it, get a friend to help support us as we fight for your practices and your profession. Donations can be made online.

Your ACR Staff and Committees

I can’t end without again acknowledging the very hard work from ACR staff, the GAC committee and the other ACR committees who work hard on our behalf. I encourage you to take a look at the ACR website and see the names of all the volunteers from across the country and across the full spectrum of ACR and ARHP membership who spend hours every week working on these issues. Our team at Greenberg Traurig has been securing very high-level meetings for us and representing us superbly in D.C. Rachel, Adam, Starla and Regina are our tireless, indomitable ACR advocacy team who do the difficult day-to-day work of protecting our interests. We owe them an amazing debt of gratitude. Now if only they could come up and shovel…

Until next time, keep fighting…

Will Harvey, MD, MSc

GAC Chair