Lawmakers Ask How to Cut Medicare Red Tape; AAFP Answers

September 08, 2017 11:51 am News Staff

Most family physicians can easily produce a list of the unnecessary regulatory burdens they wrestle with daily, so the AAFP had no trouble responding when legislators asked for examples of red tape in Medicare -- and solutions to cut through it.

[Businessman wrapped in red tape and slumped over desk]

In July, the House Ways and Means Subcommittee on Health launched an initiative called the Medicare Red Tape Relief Project( that solicited input on ways to reduce legislative and regulatory demands on health care professionals. The AAFP's detailed submission(7 page PDF) highlighted six areas where payment policy or other administrative requirements place an undue burden on family physicians.

Prior Authorization, Appropriate Use, Translation

One of the more frustrating issues for family physicians is the need to obtain prior authorization for medical items and services, said the AAFP. Not only does the process consume valuable time, but it also requires physicians to navigate different policies for different insurers.

"Family physicians must justify decisions that they can make independently based on their training, experience and judgment," the AAFP stated. "In extreme cases, the prior authorization process can even delay important and necessary treatments to patients."

Story Highlights
  • The AAFP has given the House Ways and Means Subcommittee on Health's Medicare Red Tape Relief Project recommendations to reduce the undue administrative burden family physicians bear.
  • Topping the list was an argument for prohibiting prior authorizations for procedures or items priced below a certain threshold, including generic, standard and inexpensive drugs.
  • The Academy's recommendations also addressed appropriate use criteria, translation services, evaluation and management services, quality measures, and chronic care payment.

The AAFP recommended that CMS begin by prohibiting prior authorizations for procedures or items priced below a certain threshold, including generic, standard and inexpensive drugs. When prior authorizations are required, all Medicare plans should use a standard form, which would likely be adopted by private insurers. And Medicare should pay physicians for their time whenever prior authorizations exceed a certain number of steps or are not resolved in a specified period of time.

To reduce use of advanced imaging, a pending requirement on appropriate use criteria calls for physicians who order this service for Medicare Part B beneficiaries to consult "qualified decision support mechanisms." The AAFP told legislators that this new administrative burden is unnecessary because incentives to use lower-cost services already exist in new payment models established under the Medicare Access and CHIP Reauthorization Act.

Another new burden for physicians who participate in Medicare Advantage and other programs is the requirement to provide translation services for patients with limited English proficiency. Translation is not included in office payment codes, and if a patient cancels the visit, the practice must still pay the translator.

"Family medicine practices already operate on slim financial margins," the Academy stated. "The AAFP strongly believes that Congress and HHS must procure the necessary funding to address and offset the financial burden that this mandate imposes on our members and all physicians."

The AAFP said practices should be paid for translation services or be permitted to provide them at their discretion, depending on their unique practice and patient needs.

Evaluation and Management, Quality Measures, Chronic Care Payment

Regarding documentation guidelines for evaluation and management (E/M) services, the AAFP pointed out that they were written 20 years ago during an era of paper records, and they now are a hindrance to physicians who work with care teams or electronic health records.

"Adherence to the guidelines consumes a significant amount of physician time and does not reflect the workflow of primary care physicians," the Academy stated.

The AAFP told legislators they should work with CMS to eliminate E/M guidelines and noted that the agency recently received a letter from the Academy with detailed recommendations for doing just that.

Quality measurement has become another unwarranted burden. Fifty percent of family physicians contract with seven or more payers, many of which use their own measurements to determine physician payment. In this era of value-based payment, physicians now must shift valuable -- and substantial -- time from patient care to documenting quality measures.

"This unnecessary burden can be eliminated through the adoption of a single standardized set of clinical quality measures across all public and private payers."

Specifically, Congress should require all payers to use a set of measures created by the AAFP and other participants in the Core Quality Measures Collaborative convened by CMS.

Finally, the AAFP addressed payment for chronic care management services. Although legislation requiring CMS to pay for these services was a positive step, the billing and collection procedures are overly complex. Practices must collect an $8 monthly copayment from patients for these services, which are nonface-to-face, and that can be difficult when a patient does not have an office visit in a given month.

"What amounts to a relatively modest monthly fee is dissuading beneficiaries from receiving services that are designed to keep them healthy and avoid the need for more costly face-to-face services later," the AAFP stated.

The AAFP recommended that CMS waive the copayment and simplify the billing requirements tied to chronic care.

Related AAFP News Coverage
Physician Frustration With Prior Authorizations Hits New High


New AAFP Policy Takes Aim at Prior Authorizations