The Society Joins Others in Urging CMS to Restore the Refinement Panel

August 26, 2016
Policy Snapshot

The Society, along with the American Medical Association (AMA) and 89 other organizations, sent The Centers for Medicare & Medicaid Services (CMS) a letter this week urging them to restore the Refinement Panel to serve as the relative value appeals process that was appropriately in place prior to 2011.

The AMA reviewed the need for an appeals process at this year’s AMA House of Delegates Annual Meeting and determined that having an objective, transparent, and consistently-applied formal appeals process in place is “paramount and that the original Refinement Panel process would best serve this function.”

For more than 25 years, CMS used the Refinement Panel to carefully review public comments, hear testimony from practicing physicians, and independently recommend refinement to relative values. Until recently the Refinement Panel recommendations were implemented by CMS which shows that CMS relied on them as an appeals process. However, in 2011 CMS modified the process to only consider appeals which include “new clinical information” and began to independently review each of the Refinement Panel decisions when determining which values to actually finalize.

Since these changes, CMS has “rejected the majority of requests for Refinement Panel review and only accepted 36 percent of recommendations from the Panel. With the dysfunctionality of the current iteration of the Refinement Panel process, CMS no longer relies upon outside stakeholders to provide accountability. Absent any independent mechanism for appeal, CMS officials are free to make valuation decisions without having to provide a compelling rationale when rejecting relative value recommendations from the RUC and other stakeholders.”

In the 2016 Physician Fee Schedule, CMS proposed to eliminate the Refinement Panel process but instead finalized that they would “…retain the ability to convene Refinement Panels for codes with interim final values” and that “…CY 2016 is the final year for which we anticipate establishing interim final values for existing services.” The Agency did not have to formally announce the process’ elimination to achieve the same outcome, since there will no longer be any codes eligible for review.

The Society along with the AMA and others noted their objection to the CMS intentions to make the process obsolete and urged CMS to open the Refinement Panel review to all procedures and services that are under CMS review during the current rulemaking process. The groups also noted that the original Refinement Panel was clearly a “text-book example of a standard appeals process.”