Tag: Texas Medical Association (TMA)
Modifier 25 Gets Slashed Again!
Is it October Already? Isn’t it to early for Horror stories?
I think you will find this one pretty chilling,
none the less.
Centers for Medicare and Medicaid Services (CMS) proposes to slash doctors’ payment when they bill an office/outpatient evalutation and management (E/M) service using modifier 25 on the same day as certain global procedures.
While being touted as a measure to reduce health care costs, Texas Medical Association President Bradford W. Holland, MD, warns the proposed change could create a perverse incentive under which patients who could have been treated in one visit end up having to be treated in two visits, a move he calls “unacceptable for patient care.”
Texas physicians routinely diagnose and treat patients in a single visit to avoid unnecessary care delays, and “if this modifier 25 policy is ultimately adopted, we are deeply concerned about the potential impact on patient access to timely care,” he said.
To Grasp the HORROR of it all,
Follow the Below links.
MultiPlan Provider Litigation
Federal Antitrust Litigation Seeks to Hold MultiPlan, Major Insurance Companies Responsible for Alleged Coordinated Price-Fixing Scheme
Leading to Under-Reimbursement for Out-of-Network Services
The Texas Medical Association (TMA) has joined a federal multidistrict litigation against MultiPlan (recently rebranded to Claritev) and major insurers, including UnitedHealth, Elevance, Humana, Aetna, and Cigna, alleging they conspired to systematically underpay health care practitioners for reimbursements for out-of-network services, which often fail to even cover operating costs. MultiPlan goes by many names, including Data iSight, Viant, NCN, ProPricer, and MARS. Plaintiffs allege that MultiPlan facilitated a price-fixing agreement among insurers that artificially suppressed out-of-network payment rates and cost physicians and providers billions of dollars.
TMA joins the American Medical Association (AMA) and hundreds of physician practices and facilities nationwide in this growing antitrust litigation.
“For many years, physicians in Texas have been forced to accept increasingly insufficient reimbursements for providing health care to out-of-network patients,” said TMA President Jayesh “Jay” Shah, MD. “This lawsuit is an important step to ensure that physicians are justly reimbursed for the care they provide, not only today, but also for historical underpayments going back to at least 2015, and end this alleged illegal collusion that hurts patients.”
This lawsuit, filed in the Northern District Court of Illinois in 2024, seeks to end MultiPlan’s alleged anticompetitive scheme that it has operated since at least 2015, and recoup financial damages for practitioners and practices. As of 2024, MultiPlan processes more than 80% of all commercial out-of-network reimbursement claims in the United States. Physicians and providers may not always know whether MultiPlan, or one of its services like Data iSight, Viant, NCN, ProPricer, or MARS, re-priced their claims. Clues can often be found in Explanations of Benefits or remittance advice.
Physicians who believe they have been harmed by MultiPlan and the insurance companies, whether current or in past years, can obtain a free case evaluation from one of the attorneys appointed by the court to lead the non-class claims.
The court also has appointed attorneys to litigate a proposed antitrust class action on the same issues, but a ruling on any proposed class certification is not expected until 2027. Physicians and providers who believe they have been impacted by MultiPlan’s conduct can choose to pursue their claims individually on a non-class basis and do not need to wait for any ruling on a proposed class.
Complete Your Medicaid Revalidation to Avoid Disenrollment
Texas physicians with Medicaid revalidation applications currently being processed, with deadlines on or before May 31, will be granted extensions ranging from 60 to 180 days, per the Texas Medicaid & Healthcare Partnership (TMHP).
TMHP offers the following online guidance:
- A physician who has not received a previous extension, and has a revalidation due date on or before May 31 is eligible for a first-time revalidation extension of 180 calendar days once the application is submitted (which TMHP labels “in-flight”); and
- A physician with an in-flight revalidation application already submitted and a due date on or before May 31, is eligible for a second extension of 180 days and a third extension of 60 days, plus additional 60-day extensions beyond the third.
The Texas Medical Association advises applicants who haven’t started revalidation yet to check due dates in the Provider Enrollment and Management System (PEMS), and especially if the due date is within 180 days, to fill and send their application promptly.
Also, physicians should note that a draft of an application saved in PEMS is not considered in-flight; it must be completed and submitted to gain in-flight status and thus the second and third extensions. Revalidation is not complete until an applicant’s revalidation request shows it is in “closed-enrolled” status.
Any extensions granted will be reflected in the “revalidation due dates” column on the Provider Information page of PEMS, TMHP says.
Physicians will also receive an email notification confirming their new revalidation due date once an extension is issued.
TMHP grants 165 cumulative business days to address all deficiencies on a revalidation application. If the revalidation application has unresolved issues taking it beyond that window, TMHP will close the application, requiring the physician to submit a new revalidation request.
Through its Physician Payment Resource Center, TMA offers help to physicians unfamiliar with the process or who have specific questions about using PEMS.
Last Updated On:
June 08, 2026
Originally Published On:
April 23, 2026
More Telehealth Waivers Set to Expire Dec. 31
As TMA monitors the government shutdown and the coinciding expiration of certain telehealth waivers as of Sept. 30, physicians should take notice of another series of telehealth waivers set to expire at the end of this year.
TMA staff note that Medicare Advantage plans don’t have to follow Medicare’s policy on the waiver expirations.
The following waivers enacted during the COVID-19 public health emergency (PHE) are currently expected to expire Dec. 31 unless Congress acts:
The following waivers have already expired:
TMA Coming to Tyler
Local Medicine Matters Conference Tyler, Texas
October 24-25, 2025
The Local Medicine Matters Conference is a new regional event, part of the Texas Medical Association’s initiative to hold events beyond the Texas metro areas. This inaugural conference is being hosted by the Smith County Medical Society in conjunction with TMA. The one-day event features topics of broad interest across all physician members, including practical uses of augmented intelligence in medicine, updates to billing and coding, and how physicians fared following the 2025 Texas legislative session.
Friday Night Mixer Oct. 24th
5:00 PM – 7:PM
Guest and Members Free
Saturday Conference Oct. 25th
7:30 AM – 4:00 PM
TMA Members Free
Registration
Registration for TMA members, CMS and association staff, and Alliance members is FREE – one of the many benefits of annual membership!
A $25 registration fee will be charged for on-site registrants.
Registration Fees:
Nonmember physicians: $200
Guests of members and medical staff: $150
Goverment Shutdown: What you Need to Know
With the government shutdown in effect, the Texas Medical Association is in regular communication with federal colleagues at the American Medical Association on the impact to physician practices, as AMA remains in touch with senior officials at the Centers for Medicare & Medicaid Services (CMS).
The volatility in Washington, D.C. could mean the shutdown lasts days to weeks, and TMA will share additional information via Texas Medicine Today as the situation develops. Here is what physicians need to know so far:
Medicare/Medicaid: The CMS contingency plan states that during a lapse in funding, the Medicare program will continue. CMS also says it has sufficient funding for Medicaid to fund the first quarter of 2026 and is maintaining the staff necessary to make payments to eligible states for the Children’s Health Insurance Program.
Medicare Administrative Contractors (MACs) have been instructed to implement a temporary claims hold of 10 business days, which AMA says should have minimal impact on physicians due to the 14-day payment floor. “The hold prevents the need for reprocessing large volumes of claims should Congress act after the statutory expiration date,” states a CMS Medicare Learning Network Connects special edition email newsletter that, as of this writing, had not yet been publicly posted. Physicians may continue to submit claims during this period, but payment will not be released until the hold is lifted. For the latest information, AMA recommends physicians monitor their MAC’s website (Novitas in Texas) and this CMS webpage.
“In the past, Congress generally has restored lapsed policies back to the effective date of the shutdown. During the shutdown, the AMA is monitoring any potential delays in Medicare claims processing or other Medicare payment problems that could result from federal staffing reductions at CMS, including during the shutdown,” said AMA CEO and Executive Vice President John Whyte, MD, MPH.
Telehealth: Physicians who provide telehealth services to fee-for-service Medicare patients should be aware that the Medicare telehealth flexibilities lapsed on Sept. 30 for most care and congressional action is required to restore that waiver. The exceptions are patients being treated for mental health and/or behavioral health disorder (including substance use disorders), stroke, and monthly end-stage renal disease visits for home dialysis. Otherwise, telehealth services are limited to rural areas as they were before the COVID public health emergency, and patients cannot receive telehealth services in their homes. The ability to provide audio-only services to Medicare patients also lapsed, as did the Acute Hospital Care at Home program.
The CMS newsletter suggests “practitioners who choose to perform telehealth services that are not payable by Medicare on or after Oct. 1, 2025, may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage.”
However, AMA notes physicians in certain Medicare Shared Savings Program accountable care organizations can continue to provide and be paid for telehealth services.
Other services: CMS says it is continuing federal insurance marketplace activities, such as eligibility verification. Other nondiscretionary activities including health care fraud and abuse control and Center for Medicare & Medicaid Innovation activities are also continuing.
However, AMA reports that funding extensions for community health centers, the National Health Service Corps, and teaching health centers that operate graduate medical education programs expired on Sept. 30, and the 1.0 work geographic practice cost index floor extension expired on Oct. 1. Additional programs that have lapsed include: special diabetes programs; public health emergency authorities (e.g., Public Health Emergency Fund); increased inpatient hospital payment adjustment for certain low-volume hospitals; the Medicare-Dependent Hospital program; quality measure endorsement, input, and selection; and outreach and assistance for low-income programs (e.g., area agencies on aging).
TMA wants to hear from you. If you or your practice staff experience Medicare payment delays, telehealth obstacles, or other concerns, please let us know through TMA’s Knowledge Center to help inform advocacy.
Amy Lynn Sorrel
Associate Vice President, Editorial Strategy & Programming
Division of Communications and Marketing
TMA Billing, Coding, and Payment Resources
TMA’s billing, coding, and payment page offers resources for physician practices, from one end of the continuum to the other. Educate yourself with our articles and tools, or get help with more complex questions.
Physician Payment Resource Center
TMA’s Physician Payment Resource Center (formerly known as the Hassle Factor Log and the Reimbursement, Review and Resolution Service) goes to bat for members by helping to resolve issues related to insurance payments.
TMA can help resolve issues with your payer network status, prompt-pay, and other reimbursement claims. Learn More
Billing and Coding Hotline
TMHP, New Provider Enrollment Tool
Addressing physician concerns about online Medicaid enrollment challenges, the Texas Medicaid and Healthcare Partnership (TMHP) has announced its new Provider Enrollment Assistant Tool (PEAT) is available for enrollment-related help.
Users can navigate to the help page in TMHP’s provider enrollment section to access the tool, which TMHP describes as “question-based software.” Typing in a question prompts PEAT to provide:
- Answers to revalidation questions, including due dates;
- Online appointment scheduling for personalized support with enrollment issues, including step-by-step guidance from a TMHP representative;
- Information about Provider Enrollment and Management System (PEMS) maintenance requests; and
- Instructions for new enrollments, re-enrollments, and updates to existing enrollments.
Before initiating a PEAT request, TMHP advises having at the ready your National Provider Identifier (NPI), ZIP code, taxonomy number (if applicable), and any contact information related to the NPI.
In addition to a PEAT info sheet accessible online, TMHP is offering walk-through sessions for those needing additional enrollment support, which can be scheduled via PEAT, and offers an online PEMS guide updated in March.
VA Seeking Refunds for Past CHAMPVA Claims
The U.S. Department of Veterans Affairs (VA) announced it aims to recover more than $41 million in “overpaid claims” paid to physicians and other health care professionals and entities through the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) program.
Texas Medical Association staff caution that physicians receiving CHAMPVA refund requests should take several steps to satisfy the VA request without immediately losing payment for care already delivered:
- Confirm the legitimacy of the request letter. As refund letters typically come from third-party companies, a practice may call CHAMPVA and ask them if the third-party company is one they contracted with to collect the overpayment;
- Check the letter for details on how to appeal, including any payment or appeal deadlines; and
- Check the letter for information about which insurer VA says is responsible for payment.
From there, physicians can choose one of two actions. If it appears the alleged overpayment has been identified in error, start the appeal process to try to keep the CHAMPVA payment already received. If not pursuing an appeal – or if an appeal is ultimately denied – refund the overpayment to VA and seek payment from the insurer VA says is responsible for payment. For a physician seeking payment from that insurer, TMA recommends including, as part of that request, the initial CHAMPVA explanation of benefits and any information from VA indicating that the insurer is the proper payer, especially if the filing deadline has passed.
For assistance with CHAMPVA refund requests or other payment matters, contact TMA’s Physician Payment Resource Center.
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