APMA News - January/February 2018 - 24

Reimbursement in 2018 and Beyond
Discussed at CAC-PIAC Meeting

he 17th Annual Joint National Podiatric Carrier Advisory Committee (CAC)-Private Insurance Advisory Committee (PIAC) meeting was held in November 2017 in
Baltimore. CAC and PIAC representatives are your local experts. They are practicing podiatrists with experience dealing
with insurance issues and are your go-to source when you need
help with claims appeal, contracting, understanding medical
policy, and more. (More information about the CAC-PIAC system and a summary video of the event are available online at
www.apma.org/CACPIAC.)
More than 80 representatives, volunteer leaders, and APMA
staff members came together for two days of intense reimbursement education. With a host of high-profile speakers
earned though APMA's relationships, attendees examined coming trends and details of payment models in 2018.
A significant portion of the meeting focused on the CMS
Quality Payment Program (QPP). The QPP includes the Merit-

Jodi Sengstock, DPM, responds to a comment during the CAC-PIAC
open session.

based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs). As the program
enters its second year this January and the participation requirements become more involved, APMA is working to ensure its
members remain fully informed of those requirements.
On this topic, participants heard from Tim Jackson, MIPS
scoring lead for the CMS Value-Based Incentive Group, who
addressed the major changes for MIPS in 2018, and Jeff Lehrman, DPM, a member of APMA's MACRA Task Force, who gave
a complete overview of MIPS requirements for 2017 and explained how podiatrists can participate successfully to avoid a
penalty in 2019 when the payment adjustments will occur.
(More information is available at www.apma.org/MACRA.) Additionally, APMA Director of Clinical Affairs Dyane E. Tower,
24 APMA News January/February 2018

DPM, MPH, MS, shared information about the APMA Registry,
a free APMA member benefit. The registry allows all APMA
members to complete some MIPS attestations, and members
with an integrated EHR system can complete all MIPS attestations. Learn more at www.apma.org/registry.
Another hot topic during the meeting was durable medical
equipment (DME). Paul Kesselman, DPM, DME Workgroup
chair, moderated a discussion with Michael Hanna, MPA, senior
analyst for CGS Provider Relations, DME MAC Jurisdiction C.
The session provided an update on current DME issues, including addressing the recent controversies surrounding A5513 and
positive modeling requirements, the ongoing problems with
certifying physician requirements, the increasing number of audits related to Arizona braces and L3000, and burdensome documentation requirements.
APMA consultant Kelli Back, Esq., covered private insurance
issues for attendees. One area of specific focus was the ongoing confusion providers have surrounding dual eligibles and
balance billing. She stressed the importance of providers determining their patients' status prior to billing them, as the
bulk of dual eligibles are considered to be Qualified Medicare
Beneficiaries and thus protected from balance billing of Medicare cost-sharing amounts. She also touched on Medicare Advantage trends and gave an update on the ACA provider nondiscrimination clause. Back presented with Lisa Hathaway,
Esq., vice president and chief Medicare counsel at Aetna, on
Medicare Advantage and value-based contracting.
The second day of the meeting focused on peer-to-peer education and discussions. One of the biggest areas of concern in
the private payer discussion was a recent reimbursement policy
change for Anthem providers in numerous states related to use
of Modifier 25. Specifically, when a provider bills an office-based
minor surgery with a same-day office visit, Anthem will only pay
50 percent of the allowed reimbursement for the evaluation and
management service. APMA has worked aggressively with affected state components and other stakeholders to resolve this
issue before its implementation date and already has succeeded
in delaying implementation until March and slashing the reduction in reimbursement to 25 percent. In the public payer discussion group, problematic DME denials and prior authorization
requirements continue to plague members. Problematic scopeof-practice interpretations with MACs have also become increasingly common. Representatives were able to provide advice on
how to effectively resolve these issues based on their experience
in their own regions.
Your CAC and PIAC representatives are tasked with taking the information they learned at this meeting and sharing
it with you through your state component. A list of representatives is available at www.apma.org/CACPIAC; reach out to
volunteer leaders with any questions about the meeting or any
other reimbursement concerns.
n

http://www.apma.org/registry http://www.apma.org/CACPIAC http://www.apma.org/CACPIAC http://www.apma.org/MACRA

Table of Contents for the Digital Edition of APMA News - January/February 2018