Alliance of Specialty Medicine and CSRO Support Effort to Stabilize Physician Reimbursement under the Medicare Physician Fee Schedule (MPFS)

Last week, CSRO joined the Alliance of Specialty Medicine in a letter of support for Reps. Greg Murphy, MD (R-NC) and Tom Suozzi’s (D-NY) bipartisan legislation, the Provider Reimbursement Stability Act (H.R. 8163). This bill would modernize the budget neutrality mechanisms of the Medicare Physician Fee Schedule (MPFS) to improve stability in physician reimbursement and patient access.

Medicare physician reimbursement has failed to keep pace with rising inflation, resulting in inadequate payments to physician practices. Without reform, these cuts will continue to jeopardize access to specialty care for millions of Medicare patients. The Alliance has been a leading voice calling on Congress to deliver long-overdue reform — and the Provider Reimbursement Stability Act is a critical step in the right direction.

On April 22, CSRO held several meetings on Capitol Hill to advocate for the Protecting Patient Access to Cancer and Complex Therapies Act (H.R. 4299). This bipartisan legislation is critical to ensuring continued access to Part B medications selected under the Medicare Drug Price Negotiation Program (MDPNP). CSRO and its board member, Harry Gewanter, MD, were joined by the Patient Access to Community Treatment (PACT) Coalition, of which it is a member.

The Protecting Patient Access to Cancer and Complex Therapies Act would address an unintended consequence of the MDNP that, if left unaddressed, would have a harmful impact on community physician practices. Under the Medicare Price Negotiation Program (MDPNP), Medicare can set a Maximum Fair Price (MFP) for select Part B drugs, which are typically administered in physician offices or hospital settings. Currently, physicians are reimbursed at the Average Sales Price (ASP) +6%, but the new rule would change this to the Maximum Fair Price (MFP) +6, blending MFP into ASP calculations. According to a recent Avalere study, this change could reduce Part B add-on payments by 42-61% in Medicare and 12-18% in the commercial market, threatening the financial viability of private physician practices that rely on the "buy-and-bill" model. This could force providers such as rheumatologists to transfer patients to hospitals, thereby increasing costs and potentially limiting patients’ access to medications.

The Protecting Patient Access to Cancer and Complex Therapies Act would remove physician Part B drug reimbursement from MDPNP negotiations, maintain reimbursement at ASP + 6%, and require pharmaceutical manufacturers to pay rebates to CMS for the difference between ASP + 6% and MFP + 6%. This aims to protect access to Part B medications for 60 million Medicare beneficiaries while ensuring cost savings for the government and reducing patients' out-of-pocket costs.

The American Medical Association (AMA) released an April 10 advocacy update outlining the CY 2027 Medicare Advantage final rule and its implications for physicians.

Key highlights include:

• More accurate risk score calculations through the exclusion of unlinked chart review records
• New continuity-of-care protections for certain Medicare Advantage enrollees
• A 2.48% average payment increase for plans

The update also notes ongoing concerns:

• Reduced oversight and accountability for Medicare Advantage plans
• Changes to prior authorization and utilization management requirements
• Continuing administrative challenges for physicians

Read more on the AMA website.

March 25, 2026

Provider Type(s):ALL

Moratorium on Enrollment of New Durable Medical Equipment, Prosthetics, Orthotics, and Suppliers

On February 27, 2026, The Centers for Medicare & Medicaid Services (CMS) imposed a 6-month nationwide moratorium on the Medicare enrollment of New Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) medical supply companies. A copy of the moratorium can be found here.

The goal of the temporary moratorium is to fight fraud and safeguard taxpayer dollars, while ensuring patient access to care. Authority to impose such moratoria was included in the Affordable Care Act, and the Agency for Health Care Administration (Agency), with the approval from CMS, is exercising that authority at this time.

Effective March 20, 2026, the Agency has imposed a temporary Medicaid moratorium on enrollment of new Durable Medical Equipment DME providers (Provider Type 90) in all Florida counties.

Exclusively for purposes of the moratorium's applicability, a medical supply company is considered a business whose principal function is to furnish durable medical equipment and medical supplies (regardless of supply type) directly to another party, such as, but not limited to: (1) recipients with a medical order (for example, via mail order); (2) medical providers and suppliers; or (3) both. A pharmacy, hospital, or other medical provider that also provide DME as a secondary function are not part of this moratorium.

The statewide moratorium will remain in place for an initial 6-month period. Under the moratorium, the Agency will not accept any new applications for DME providers for Florida Medicaid enrollment that are received after March 20, 2026. The Agency will continue processing DME provider applications submitted on or before March 20, 2026.

No Medicaid recipients will go without the services they need. If any recipient is having difficulty accessing services, please encourage them to contact the Florida Medicaid Helpline at (877) 254-1055.

All existing DME providers can continue to deliver and bill for authorized services.

QUESTIONS? FLMedicaidManagedCare@ahca.myflorida.com

COMPLAINTS OR ISSUES? ON LINE ahca.myflorida.com/Medicaid/complaints/ | CALL 1-877-254-1055

The Agency for Health Care Administration is committed to its mission of providing "Better Health Care for All Floridians." The Agency administers Florida’s Medicaid program, licenses and regulates more than 48,000 health care facilities and 47 health maintenance organizations, and publishes health care data and statistics at FloridaHealthFinder.gov . Additional information about Agency initiatives is available via Facebook (AHCAFlorida) and  Twitter (@AHCA_FL)

Florida Medicaid Health Care Alert

November 13, 2025

Provider Type(s): ALL

Medicaid Modernization: Start Preparing for New Provider Enrollment System

Source: State of Florida Agency for Health Care Administration

The Florida Agency for Health Care Administration (AHCA) is launching a new provider enrollment system in early 2026 as part of the AHCA Enterprise modernization. This modernization will streamline enrollment, renewal, and account maintenance, making the process faster, easier, and more secure for Medicaid providers.

In preparation, providers should:

• Complete pending enrollments in the current Medicaid Provider Enrollment Application Wizard.
• Review and update account information in the Medicaid Secure Web Portal. If renewal has been triggered, complete renewal there.
• Active Medicaid providers who have not created an account should do so as soon as possible. If you do not have your PIN information, see Password Resets and PINs for support.
• Subscribe to Florida Medicaid Health Care Alerts for updates.

Account Maintenance How-tos:

• Update account information: Account Management – Modify Contact Information.
• Reset password: Visit the Medicaid Secure Web Portal and select “Reset password.”
• Maintain an active account: Log in every 60 days before the password expires.
• Newly enrolled providers will receive a PIN letter within 10 business days. Visit https://public.flmmis.com/public/pinletter/ to activate your account.

Resources:

• Password Resets and PIN Instructions
• Account Maintenance and Reset Password Quick Reference Guide
• Secure Web Portal User Guide

Launching in early 2026, the new Provider Enrollment System will:

• Give providers 24/7 access to their provider account from any device.
• Provide step-by-step instructions so applications are right the first time.
• Make enrollment, renewal, and account maintenance faster and more secure.

What’s Next?

As launch day approaches in early 2026, AHCA will share updates through Florida Medicaid Health Care Alerts, including when new preparation tools become available.

As part of this effort, the Florida Society of Rheumatology has signed on to the coalition letter that will be sent to House and Senate leadership when Congress returns this month. It is crucial that Congress addresses this issue before the end of 2024 to ensure fair and sustainable Medicare payments for clinicians in 2025 and beyond.

The recently published FAQ document offers some clarification on the use of this code, including details related to its documentation requirements.

Click Here to Read Press Release

Today, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), proposed new policies in the calendar year (CY) 2025 Medicare Physician Fee Schedule (PFS) proposed rule to advance health equity and support whole-person care. The proposed rule would also strengthen primary care, expand access to behavioral health, oral health, and caregiver training services, maintain telehealth flexibilities, and expand access to screening for colorectal cancer and vaccinations for hepatitis B. The proposed rule reflects the Biden-Harris Administration’s vision for affordable, high-quality care for all Americans while driving innovation in the Medicare program. 

“This proposed rule strengthens the care people with Medicare receive, advancing HHS’s goal of a health care system that not only treats those who are sick but also keeps people well,” said HHS Secretary Xavier Becerra. “The proposed rule continues our implementation of President Biden’s historic prescription drug law. The law lowers costs for seniors and people with disabilities and uses rebates from drug manufacturers to strengthen Medicare. It also increases access to behavioral and dental care, expands access to cancer screenings, and supports caregivers.” 

“The Biden-Harris Administration is committed to protecting and expanding Americans’ access to quality, affordable health care,” said CMS Administrator Chiquita Brooks-LaSure. “The Calendar Year 2025 Physician Fee Schedule proposed rule supports physicians and other practitioners in delivering care that meets the needs of people with Medicare, including through telehealth flexibilities, strengthened primary, behavioral, and oral health care, and improved access to caregiver training services.” 

Because of factors specified in law, average payment rates under the PFS are proposed to be reduced by 2.93% in CY 2025 compared to the average amount these services will be paid for most of CY 2024. The change to the PFS conversion factor incorporates the zero percent overall update required by statute, the expiration of the 2.93% increase in payment for CY 2024 required by statute, and a small adjustment necessary to account for changes in valuation for the work RVU portion of particular services. This amounts to a proposed estimated CY 2025 PFS conversion factor of $32.36, a decrease of $0.93 (or 2.80%) from the current CY 2024 conversion factor of $33.29.

“Whole-person care means moving towards a health-care system that recognizes each unique aspect of a person and their wellbeing, including physical health, behavioral health, oral health, social determinants of health, and caregiving supports, and it all starts first with a foundation of primary care that can integrate these components,” said Meena Seshamani, M.D. Ph.D., Deputy CMS Administrator and Director of the Center for Medicare. “We are taking lessons learned from numerous CMS Innovation Center models to strengthen primary care teams and accountable care organizations, allowing them to better meet the unique needs of every person with Medicare.”

Strengthening Primary Care while Driving Quality Improvement and Innovation

A person-centered approach to health care starts with a trusting relationship with a primary care team. Over the last decade, value-based primary care models tested by the CMS Innovation Center have demonstrated that comprehensive primary care can lead to reductions in emergency department and hospital visits while better meeting patient needs. CMS is proposing to use these lessons learned to establish a new, advanced primary care management bundle under the PFS. As an important first step as part of a multiyear effort, this proposed payment uses coding describing certain primary care services that would be provided by advanced primary care teams, with adjustments for patient medical and social complexity to promote health equity. These services would be tied to primary care quality measures to improve health outcomes for people with Medicare. 

In addition, the Innovation Center’s Million Hearts® model demonstrated that payment for cardiovascular risk assessment and cardiovascular care management led to fewer deaths related to cardiovascular disease and important reductions in heart attacks and strokes. Based on these evaluation results, CMS is proposing new payment and coding for these services to better assess and manage heart health. 

CMS continues to drive high-quality care through its Quality Payment Program and is continually strengthening the Merit-based Incentive Payment System (MIPS). This rule proposes six new MIPS Value Pathways (MVPs): ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care. CMS is also proposing updates to MIPS scoring methodologies and measure inventories to give all clinicians the opportunity to achieve positive scores and continued improvement. These updates will help ensure that all eligible clinician types can continue to meaningfully participate in MIPS as CMS transitions to MVPs.

To further leverage progress on MVP development, the RFI “Building Upon the MVP Framework to Improve Ambulatory Specialty Care” solicits feedback on the design of a potential model to increase the engagement of specialists in value-based care. Under the potential model, participants would receive a payment adjustment based on their performance compared to other similar specialists on a set of clinically relevant MVP measures. 

CMS is also proposing to strengthen the Medicare Shared Savings Program (Shared Savings Program) further, which is Medicare’s permanent Accountable Care Organization (ACO) program. For the first time, CMS is proposing to allow eligible ACOs with a history of success in the program access to an advance on their earned shared savings, known as prepaid shared savings, to encourage investment in staffing, health care infrastructure, and additional services for people with Medicare, such as nutrition support, transportation, dental, vision, hearing, and Part-B cost-sharing reductions.

Additionally, CMS is proposing to further incentivize participation in the Shared Savings Program by ACOs that serve people with Medicare who are members of rural and underserved communities by adopting a health equity benchmark adjustment similar to that in the Innovation Center’s ACO REACH Model, which has been associated with increased safety net provider participation. CMS is also proposing to move the Shared Savings Program towards the Universal Foundation of quality measures, creating better quality measure alignment for providers and driving care transformation. Further, CMS is proposing a methodology to account for the impact of improper payments when reopening an ACO’s shared savings and shared losses calculations, which is complementary to the Anomalous Increases in Billing on Medicare Shared Savings Program Financial Calculations Proposed Rule issued on (June 28, 2024).  The proposed adjustments described in both rules would improve the accuracy, fairness, and integrity of Shared Savings Program financial calculations. 

Expanding Access to Behavioral Health, Oral Health, and Caregiver Training Services

Addressing the country’s behavioral health crisis continues to be a key priority for CMS. In support of the President’s whole-of-government strategy to transform how we address behavioral health, CMS is proposing several additional, impactful changes in this year’s rule. CMS is proposing new payments for practitioners who are assisting people at high risk of suicide or overdose, including separate payment for safety planning interventions and post-discharge follow-up contacts. CMS is also proposing new payment and coding for use of digital tools that further support the delivery of specific behavioral health treatments, and also new coding and payment to make it easier for practitioners to consult behavioral health specialists. For Opioid Treatment Programs (OTPs), this rule also proposes new codes for FDA-approved medications for the treatment of Opioid Use Disorder (OUD) and known or suspected opioid overdose, increased telecommunication flexibilities for periodic assessments and methadone treatment initiation, and an increase in payment for intake activities to provide more comprehensive services for the treatment of OUD, including assessing for unmet health-related social needs, harm reduction intervention needs, and recovery support service needs. 

In response to public feedback about Medicare coverage of dental services, CMS continues to explore payment policies for dental services critical to the success of certain medical care. CMS previously finalized that payment can be made for dental exams and certain necessary diagnostic and treatment services in connection with organ transplants (including stem cell and bone marrow transplants), cardiac valve replacements, valvuloplasty procedures, head and neck cancers, chemotherapy, chimeric antigen receptor T- (CAR-T) cell therapy and high-dose bone modifying agents (antiresorptive therapy). In this year’s rule, CMS proposes that payment can be made for certain dental services associated with dialysis treatments for end-stage renal disease and includes a request for comment about dental services related to diabetes care and covered services for individuals with autoimmune diseases receiving immunosuppressive therapies.

Finally, caregivers provide crucial, daily care to many people with Medicare, and CMS continues to prioritize caregiver training services consistent with the Biden Administration Executive Order on caregiving. In this year’s rule, CMS proposes new payment for caregiver training services related to direct care services and supports and would allow caregiver training services to be provided virtually, as clinically indicated. 

Expanding Preventive Services: Hepatitis B Vaccinations, Drugs Covered as Additional Preventive Services, and Colorectal Cancer Screenings

CMS is proposing to expand coverage of the hepatitis B vaccine for people with Medicare who have not received the hepatitis B vaccine or whose vaccination status is unknown, with no cost to the individual. We are also proposing to allow people with Medicare to get the hepatitis B vaccine from pharmacies and to allow pharmacies and mass immunizers to roster bill Medicare consistent with current billing for flu, pneumococcal, and COVID-19 vaccines. 

CMS is also proposing a fee schedule for drugs covered as additional preventive services since CMS has not yet covered or paid for any drugs under the benefit category of additional preventive services. On July 12, 2023, CMS released a Proposed NCD for Pre-Exposure Prophylaxis (PrEP) for Human Immunodeficiency Virus (HIV) Infection Prevention, which proposes to cover HIV PrEP drugs under Part B as additional preventive services. 

CMS is also proposing to update and expand coverage of colorectal cancer screening to promote access and remove barriers for much needed cancer prevention and early detection, that may be especially important within rural communities and communities of color.

Maintaining Telehealth Flexibilities

During the COVID-19 public health emergency, CMS took action to expand access to telehealth services to ensure people could continue to access health care. Congress’ temporary extension of flexibilities related to payment for many telehealth services is scheduled, by statute, to expire at the end of 2024. In that context, CMS continues to examine telehealth and its impact on access and quality. Proposals in this year’s rule would allow CMS to maintain some important, but limited, flexibilities where possible and reflect CMS’ goal to maintain and expand the scope of and access to telehealth services where appropriate. For example, these proposals would continue to permit certain practitioners to provide virtual direct supervision to auxiliary personnel when required. CMS is also proposing temporary extensions of virtual supervision for a broader range of services when teaching physicians virtually supervise telehealth services provided by residents in teaching settings. However, absent Congressional action, beginning January 1, 2025, the statutory restrictions on geography, site of service, and practitioner type that existed prior to the COVID-19 PHE will go back into effect. After that date, people with Medicare will need to be in a rural area and a medical facility to receive non-behavioral health services via Medicare telehealth.

Inflation Reduction Act Implementation

The Inflation Reduction Act, President Biden’s prescription drug law, discourages runaway price increases by drug companies by requiring them to pay rebates to Medicare when prices increase faster than the rate of inflation for certain drugs under Part B and Part D. Additionally, Part B drugs that have raised prices faster than inflation in a given quarter will have a lower Part B coinsurance amount in a subsequent quarter. CMS will invoice drug companies for rebates owed to Medicare for Part B drugs for all calendar quarters in 2023 and 2024 no later than September 30, 2025, and for rebates owed to Medicare for Part D drugs for the 12-month applicable periods beginning October 1, 2022, and October 1, 2023, no later than December 31, 2025. The rebate amounts paid by drug companies will be deposited into the Federal Supplementary Medical Insurance Trust Fund, which will help ensure the long-term sustainability of the Medicare program for future generations. The CY 2025 PFS proposed rule codifies and builds on finalized guidance to continue implementation of the inflation rebates and proposes the next phase of implementation.

The 60-day comment period for the CY 2025 PFS proposed rule (CMS-1807-P) ends September 9, 2024.

For a fact sheet on the CY 2025 Physician Fee Schedule proposed rule, please visit: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2025-medicare-physician-fee-schedule-proposed-rule

For a fact sheet on the CY 2025 Quality Payment Program proposed changes, please visit: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2876/2025-QPP-Proposed-Rule-Fact-Sheet-and-Policy-Comparison-Table.pdf

For a fact sheet on the proposed Medicare Shared Savings Program changes in the CY 2025 PFS proposed rule, please visit: https://www.cms.gov/newsroom/fact-sheets/fact-sheet-calendar-year-cy-2025-medicare-physician-fee-schedule-proposed-rule-cms-1807-p-medicare

For a fact sheet on the proposed Medicare Prescription Drug Inflation Rebate Program changes in the CY 2025 PFS proposed rule, please visit: https://www.cms.gov/files/document/medicare-prescription-drug-inflation-rebate-program-proposed-rule-fact-sheet.pdf

To view the CY 2025 Physician Fee Schedule and Quality Payment Program proposed rule, please visit: https://www.federalregister.gov/public-inspection/2024-14828/medicare-and-medicaid-programs-calendar-year-2025-payment-policies-under-the-physician-fee-schedule

The Florida agency that oversees Medicaid imposed more than $33 million in sanctions against the health plans responsible for providing coverage in the past fiscal year.

Data culled by the Agency for Health Care Administration (AHCA) shows that as of June 28, the agency took 288 final actions during the fiscal year that started on July 1, 2023. All but one of those final actions resulted in liquidated damages, totaling $33.2 million. Simply Healthcare was the sole Medicaid managed care plan to be sanctioned but the amount was for just $2,500, according to the agency’s compliance dashboard.

Even though Medicaid is financed through state and federal tax dollars, the bulk of the program is run through privately held companies that have contracts with the state to offer Medicaid coverage.

The AHCA data shows that Sunshine Health had the most final actions taken against it with 36, followed by UnitedHealthcare with 35 and Humana Medical Plan with 33.

But AHCA regulators levied nearly $13.8 million in liquidated damages against Sunshine Health, far more than the $2.29 million in damages levied against United Healthcare and $2.3 million in damages levied against Humana Medical Plan.

According to the AHCA website the vast majority of the liquidated damages against Sunshine, or 93%, are due to one final action stemming from a “desk review.”

Sunshine State has more members than any other plan with more 1.1 million enrollees.

Every contracted health plan had liquidated damages levied against them in FY 2023-24 as a result of desk reviews according to the website. Indeed, desk reviews accounted for the majority of the liquidated damages for the fiscal year 2023-24.

The number of final actions taken against the health plans in FY 2023-24 increased by 36 from the previous fiscal year. The amount in liquidated damages in FY 2023-24 increased by more than $30 million compared to the previous fiscal year.

The data is not final and includes administrative actions and sanctions through June 28.

The state fiscal year ended on June 30.

AHCA is in the midst of its statewide Medicaid managed care procurement and the existing contracts are expected to come to an end at the end of the year. Eleven managed care plans responded to the state’s invitation to negotiate new Medicaid managed care contracts. AHCA announced in April its intent to sign contracts with Florida  Community Care, Humana Medical Plan, Simply Healthcare Plans, Sunshine State Health Plan and South Florida Community Care Network.

Several plans — Aetna Better Health of Florida; AmeriHealth Caritas Florida; Florida Community Care; ImagineCare; Molina Healthcare of Florida; Sentara Care Alliance; South Florida Community Care Network, d/b/a Community Care Plan; and UnitedHealthcare of Florida — filed notices of intent to challenge the Medicaid Managed Care ITN decision, according to AHCA’s office of public information.

AHCA has not made the challenges available for public review. But none of the challenges have been officially filed in state administrative court, an indication that the agency is continuing to try to negotiate settlements with the managed care plans that have threatened legal action.

AHCA wants the new plans to take effect Jan. 1, 2025.

Meanwhile, AHCA’s compliance dashboard shows that the state has taken 1,213 final actions against the health plans during the six years the current contracts have been in effect. All but three of those final actions resulted in liquidated damages. Just $9 million in sanctions were levied.

Unlike sanctions, liquidated damages are not intended to be punitive in nature but instead are estimates of the state’s projected financial loss and damage resulting from non-performance.

Source: https://floridapolitics.com/archives/682813-medicaid-managed-care-plans-popped-with-more-than-33m-in-liquidated-damages-last-year/

Effective May 30, a provider or supplier may be subjected to a stay of enrollment if they are deficient in one provider enrollment requirement which can be remedied by submitting a provider enrollment application. A stay of enrollment is a preliminary, interim status representing a pause in enrollment during which you will not be paid.

During a stay of enrollment, or pause, your provider status remains active in Medicare, but Medicare will reject all claims submitted with a date of service within the stay period.
 
Some examples of when a stay of enrollment may be implemented:

• Provider failed to timely report a change in address
• Supplier didn't respond to a revalidation request
• Independent diagnostic testing facility failed to comply with a supplier standard
• A supplier failed to timely report a change in address of an organizational owner
• A supplier failed to report the deletion of a managing employee

Note: If a stay of enrollment has been placed on your enrollment record, you will be notified by hard-copy mail, email, and fax, if applicable. To have the stay of enrollment removed, you must fix the non-compliance with Medicare by submitting the applicable Medicare application. Remember, if you need help, Acevedo Consulting has the expertise to assist with Medicare enrollment.
 
For example: Your clinic group practice recently changed practice locations and did not notify Medicare. Your MAC implemented a stay of enrollment because you did not report a change in practice location. To have the stay of enrollment removed and be able to continue billing Medicare, you will have to submit a change of information enrollment application to update your practice address.

If you believe you meet all provider enrollment requirements and the stay of enrollment should not have been imposed, you can submit a provider enrollment rebuttal. Refer to your stay of enrollment letter for instructions on how and where to submit the rebuttal.
 
 
For more information, click here. 

Source: Acevedo Consulting 

https://www.acevedoconsultinginc.com/