Speak Up, Be Heard

CMS resolutions go to medicine’s legislative body, the House of Delegates

THE CHICAGO Medical Society’s grassroots resolutions process lays the foundation for strong physician advocacy, in Springfield and Washington. Each year CMS works with individuals and committees to craft new measures and then relay them to the Illinois State Medical Society’s House of Delegates. And when the HOD meets this April 21-23, your CMS will be there to launch and support these efforts.

Already, two powerful CMS resolutions from years past are having an impact. In 2016, our Network Adequacy Taskforce drafted language that ISMS transformed into a bill (HB 311 and SB 70) that establishes network adequacy standards for all health plans sold in the state. The provisions, as proposed by CMS, require plans to maintain up-to-date directories of in-network providers, and to communicate any changes to patients clearly and quickly.

Another CMS effort being implemented by ISMS would amend the Illinois Insurance Code so that health plans can no longer deny benefits claiming a procedure is not medically necessary, or refer to medical necessity, when the denial is based on coverage levels.

Here’s a snapshot of CMS resolutions bound for ISMS:

Hospital and Health System Administrator Compensation

• Requests the AMA to study the compensation of hospital administrators and hospital network administrators in not-forprofit hospitals and health systems and to evaluate whether their compensation is consistent with their mission to provide care to the indigent and the public in general.

• Requests the AMA to report the study results in its physician-publications and submit the results to other medical and non-medical publications.

Reimbursement for Prior Authorization

• Calls for state and national legislation that requires insurance companies and pharmacy benefit managers (PBMs) to pay for each prior authorization form submitted.

• Directs the AMA CPT Editorial Panel to create a new billing code as necessary so that physicians are able to bill insurance companies and PBMs for the time spent on each prior authorization.
Inappropriate Requests for DEA Numbers

• Creates state and national registries to collect data on the circumstances under which physicians are asked to provide DEA numbers for reasons that do not involve controlled substances.

• Seeks legislation in Illinois to penalize companies and entities that request physicians to provide their DEA numbers for uses outside their intended purpose.
Advanced Care Planning Codes

• Calls for an assessment of the use of Advanced Care Planning 99497 and 99498 Codes, and the barriers to advanced care planning discussions by physicians and patients.

• Enables use of Codes 99497 and 99498 when sufficient time and effort is spent with patients and families over multiple clinical visits to satisfy the time requirements.

Opposing Attorney Presence and/or Recording of IMEs

• Calls for study of state and federal policy that would prohibit courts from compelling the recording, videotaping, or allowing a court reporter or opposing attorney to be present during the IME as a condition for medical opinions being allowed in court.

• Supports or introduces legislation to accomplish the above.

• Adds such policy to the 7th Edition of the AMA’s Guides to the Evaluation of Permanent Impairment.

Acceptance of Hospital-Based Serum Alcohol Results in Litigation

• Seeks legislation so that courts will:
1. Accept these test results without further expert testimony unless documented irregularities exist in the medical record.
2. Not require chain-of-custody documentation to prove the integrity of a hospital-based alcohol test used for clinical purposes.
3. Recognize there is no clinical difference (and minimal analytical difference) between a hospital-based serum alcohol test and whole blood alcohol concentration and adjudicate as such.
4. Not interpet hospital-based alcohol testing as “speculative” and not bar such testing unless there are documented irregularities in the medical record.
5. Not consider the disinfectant used to draw blood a reason to disqualify the result.
6. Allow hospital-based alcohol concentrations to be admissible as evidence of intoxication even without other evidence.

Making Voice Recognition Systems Available in EHRs

• Seeks legislation that requires the integration of voice recognition systems into all electronic medical record systems.

Improving the Insurance Appeals Process

• Requires insurance companies to state in their prior authorization assessment the criteria by which a procedure was denied, and to provide the criteria for approval in the denial letter to the physician and patient.

Pharmaceutical Price Relief

• Educates policymakers and others about the non-competitive and deleterious effects of PBMs in the medication supply chain.
Tobacco Harm Reduction: A Comprehensive Nicotine Policy

• Educates physicians on patient-specific approaches to smoking cessation, particularly patients with end-stage disease secondary to smoking and those who have failed traditional cessation methods.

• Calls for research to expand options for assisting in the transition from smoking, including nicotine replacement therapies and noncombustible nicotine products (including e-cigarettes).

If you would like to serve as a CMS delegate, please call 312-670-2550.