American Academy of Family Physicians
Monday Jan 07, 2013

Webinar to discuss what's new in Medicare and Medicaid payment in 2013

With the Medicare payment cliff averted for now, Medicare payments should be fairly stable for a while. However, that does not mean there are no changes in store for Medicare and Medicaid this year.

From Medicare adding two new codes for transitional care management to Medicaid payments for some primary care services rising to the level of Medicare to the continuing use of Physician Quality Reporting System (PQRS) bonuses, it's going to be a busy year for family physicians understanding and taking advantage of the new payment rules.

My colleague Debra Seyfried and I will be covering these and other aspects of Medicare payment in 2013 during a live webinar at 1:00 p.m. (Central Standard Time) on Jan. 23, 2013. I would invite you to join us by registering online. It could make a difference to your bottom line this year and in years to come.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday Dec 21, 2012

Medicare's impending fiscal cliff for physicians

If the federal government does go over the "fiscal cliff" in a little more than a week, don't expect those overseeing physician reimbursements to pad the fall.

The Centers for Medicare and Medicaid Services (CMS) on Dec. 19 announced in an email and conference call with physicians that Medicare claims filed after the first of the year will be processed as normal, which means likely including a planned 26.5 percent reduction in the Medicare physician services conversion factor.

Physicians are also facing an additional 2 percent cut in the Medicare physician payment rate because of the Budget Control Act's sequestration provision.

Under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt. In similar past situations, CMS has taken advantage of that provision to have its contractors hold claims for up to 10 business days before processing them, in order to give Congress more time to act and to avoid processing claims twice when the conversion factor is in flux.

“The negative update of 27 percent under current law for the 2013 Medicare Physician Fee Schedule is scheduled to take effect on January 1, 2013,” CMS wrote in the email. “Given the current progress with the legislation, CMS must take steps to implement the negative update.”

CMS did say that it would notify physicians on or before Jan. 11, 2013, about the status of Congressional action to avert the negative update and next steps. Claims with dates of service on or before Dec. 31, 2012, will be unaffected in any case.

Ongoing efforts to avoid the cliff and override the planned rate reduction have so far failed and won't resume until after Christmas at the earliest.

In the meantime, you are advised to start taking steps to mitigate the disruption and meet your own financial obligations in January, in case the cuts actually take effect. This includes re-assessing your Medicare participation options and the extent to which you can continue to afford to care for Medicare beneficiaries. If you decide to limit your involvement with the Medicare program, notify your Medicare patients promptly, so that they, too, can explore other options to seek health care and medical treatment. Finally, you are encouraged to contact your Congressional representatives about this matter, and the American Academy of Family Physicians has provided a convenient means to do so.

–Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Dec 18, 2012

New rule would let more family physicians treat veterans

While many family physicians want to treat the military veterans in their communities, the Department of Veterans Affairs (VA) hasn't always made that easy. Thankfully, the VA recently began taking steps to loosen its regulations in such a way that family physicians could have greater ability to serve veterans and get paid by the VA for doing so.

Under current law, private physicians can provide certain hospital care and medical services to eligible veterans when VA facilities either are not accessible or aren't able to provide the necessary care. These services are provided under the Non-VA Care program. However, the program allows that non-VA care only if the veteran initially received treatment during a period of hospitalization.

Last month, the VA published a proposed revision to this regulation in the Federal Register. The change would enlarge the list of eligible providers where the veteran initially received care to include nursing homes, domiciliary care, or other medical services. The VA could authorize non-VA treatment under the program for up to 12 months, with the option of additional reauthorizations as needed.

The American Academy of Family Physicians (AAFP) enthusiastically supports this step since it improves health care access for veterans and will allow the VA to better utilize community resources. Separate from this proposed regulation, the AAFP is encouraging the VA to identify and remove additional barriers that inhibit the way community-based family physicians are able treat their patients who also happen to be veterans. Specifically, the AAFP is urging the VA to reexamine a burdensome regulatory requirement that in order for a veteran to obtain a prescription at the VA's discounted price it has to be written by a VA-affiliated provider. Instead, AAFP believes the VA should recognize the validity of a community-based physician's prescription.

The VA’s recent proposal won’t eliminate all of the barriers that community family physicians face in trying to serve veterans. However, it appears to be a step in the right direction for both veterans and their family physicians.

 –Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday Aug 31, 2012

AAFP responds to proposed rule on 2013 Medicare physician fee schedule

On Aug. 22, 2012, the American Academy of Family Physicians (AAFP) responded to the proposed rule on the 2013 Medicare physician fee schedule. As promised, I am sharing that response with you. Here are some of the highlights; the AAFP:

  • Supports the Centers for Medicare & Medicaid Services' (CMS) proposal to create a code for post-discharge transitional care management as a short-term payment strategy; however, the AAFP urges CMS to limit the use of the code to the patient's primary care physician,
  • Supports CMS’s intent to investigate potentially misvalued codes, especially in regard to the number and level of post-operative evaluation and management services assumed to be included in global surgical services,
  • Urges CMS to not implement the Institute of Medicine recommendations pertaining to geographic practice cost indices, and instead asks that CMS refocus it's efforts on ensuring a properly distributed healthcare workforce that is meeting the demands of a growing beneficiary population,
  • Agrees with the proposal to add coverage of ‘‘additional preventive services’’ and supports the proposal to add them to the list of Medicare telehealth services for 2013; however, the AAFP questions several of the proposed payment amounts for these services,
  • Supports the CMS proposal to create new criteria for being a successful electronic prescriber for groups of two to 24 eligible professionals,
  • Strongly supports CMS’s proposal to streamline the implementation of the Physician Quality Reporting System incentive and reporting programs within the context of the Medicare Shared Saving Program,
  • Mostly supports the CMS proposal to begin applying the value-based payment modifier only to groups of 25 or more eligible providers in 2015, so the agency can begin learning how to properly fulfill the statutory requirements; however, the AAFP remains concerned with CMS’s inability to specify the exact amount of the upward payment adjustment because of budget neutrality considerations,
  • Fully supports the agency’s proposal to begin Medicare Part B coverage of the Hepatitis B vaccine for high-risk groups, specifically persons with diabetes.

The full text of the AAFP response is available online.

The comment period for the proposed rule ends on Sep. 4, 2012. After that deadline, we will have to wait for the final rule to see what CMS decides to do on all of these issues. CMS is expected to release the final rule on the 2013 Medicare physician fee schedule on or around Nov. 1, 2012.

Thursday Aug 16, 2012

Medicare physician fee schedule redux

In a previous blog, I posted about the proposed rule on the 2013 Medicare physician fee schedule. I subsequently received questions regarding whether or not the American Academy of Family Physicians (AAFP) had any involvement in the creation of the proposed 2013 fee schedule and what impact the fee schedule might have on family physicians. To the best of my knowledge, AAFP was not directly involved in the creation of the proposed 2013 Medicare physician fee schedule. The Centers for Medicare & Medicaid Services (CMS) essentially reserves sole responsibility for its creation.

AAFP  advocates with CMS throughout the year on elements of the physician fee schedule, and the results of that advocacy can be seen in CMS's estimate of the proposed rule's impact on family medicine. Specifically,  CMS estimates that family physicians will experience approximately a 7 percent increase in Medicare allowed charges in 2013, based on what is in the proposed rule (see page 12 of the AAFP's summary of the proposed rule). That percentage is higher than any other specialty listed. So, although AAFP can't take responsibility for creating the proposed rule, it can certainly take some credit for the estimated positive impact on family physicians.

AAFP is preparing a response to the proposed rule in advance of the Sep. 4, 2012, deadline for comments, and I look forward to sharing that with you in a future post. In the meantime, thanks for the questions, and please let me know if you have more.  

Monday May 09, 2011

Shields and swords

What is the difference between a shield and a sword?  Sometimes, it's hard to tell and may depend on where you sit.  This point was driven home to me recently in an exchange of correspondence between the AAFP and Wisconsin Physician Services (WPS), the Medicare contractor that processes Part B claims in several Midwestern states.     

Earlier this spring, the AAFP submitted comments to WPS regarding a draft local coverage determination (LCD) that WPS posted regarding home and domiciliary services (PDF download).  The AAFP expressed at least four concerns with the LCD, and it was clear from our comments that our primary concern was that WPS would use the LCD as a sword to unfairly penalize physicians who do home visits. 

Although WPS does not typically respond individually to comments made regarding draft LCDs, it did choose to respond to the AAFP comments in this case.  In doing so, it noted that a review of medical records for claims submitted by Part B providers in place of service "home" when the beneficiaries were also concurrently being seen by a home health agency showed that the service billed by the Part B provider was seldom, if ever, the service actually rendered.  WPS also shared statistics showing that utilization of home visit codes paid under the Medicare physician fee schedule was significantly higher in WPS's service area as compared to national averages, with financial implications for the Medicare trust fund.  From the letter, it was apparent that WPS viewed the draft LCD as a shield designed to protect Medicare and its beneficiaries. 

So, is the LCD a sword or a shield?  The answer clearly depends on whom you ask and, ultimately, how it is used.  In any case, the point of the story is that, when dealing with Medicare (and, likely, other payers, too), it is important to remember that there are often legitimate differences in perspective that must be acknowledged and addressed if true dialogue and progress is to occur. 

Friday Mar 11, 2011

Facing the new face-to-face requirement for Medicare home health services

Did you know that Medicare will soon begin enforcing a requirement that a physician who certifies a patient as eligible for Medicare home health services must see the patient either within 90 days prior or 30 days after the start of home health care? If not, read on. If so, you may still want to read on for more information.   

As an outgrowth of section 6407 of the Patient Protection and Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) is requiring that a physician who certifies a patient as eligible for Medicare home health services must see the patient. The law also allows the requirement to be satisfied if a non-physician practitioner (NPP) sees the patient, when the NPP is working for or in collaboration with the physician. The provision was effective as of Jan. 1, 2011, but CMS agreed in December to delay enforcement until April 1, 2011. 

The provision requires that, as part of the certification form itself, or as an addendum to it, the physician must document that the physician or NPP saw the patient, and document how the patient’s clinical condition supports a homebound status and need for skilled services. As noted, the face-to-face encounter must occur within the 90 days prior to the start of home health care or the 30 days after the start of care. When a physician orders home health care for the patient based on a new condition that was not evident during a recent visit, the certifying physician or NPP must see the patient within 30 days after admission.

The new requirement includes several features intended to accommodate physician practices. In addition to allowing NPPs to conduct the face-to-face encounter, Medicare will allow a physician who attends to the patient but does not follow the patient in the community, such as a hospitalist, to certify the need for home health care based on their face-to-face contact in the hospital and to establish and sign the plan of care. Medicare will also allow such physicians to certify the need for home health care based on their face-to-face contact with the patient, initiate the orders for home health services, and “hand off” the patient to his or her community-based physician to review and sign off on the plan of care. Finally, in rural areas, the law allows the face-to-face encounter to occur via telehealth, in an approved originating site.

The American Academy of Family Physicians and others are advocating with CMS to extend the enforcement date to no earlier than July 1, 2011, based on confusion with and resistance to the paperwork obligations for physicians, still evolving policy interpretations and guidance on the part of CMS, and the simple need for more time to ensure that physicians and NPPs understand the rule. A decision by CMS on this request is still pending, so as of now, April 1, 2011, remains the key date.   

CMS has made additional guidance available via an article (PDF download) on the Medicare Learning Network web site.  Additionally, CMS has posted frequently asked questions and answers regarding this requirement in the Spotlights section of the Home Health Agency Center section of the CMS web site.  

Friday Nov 05, 2010

The 2011 Medicare physician fee schedule is here

This week, the Centers for Medicare and Medicaid Services (CMS) unveiled its final rule on the 2011 Medicare physician fee schedule

An initial review shows positive news with respect to the primary care bonus that is effective in 2011. CMS apparently responded positively to comments from the American Academy of Family Physicians and others to change the primary care incentive payment implementation rules to make it more inclusive. As a result, CMS estimates that, under the new, less restrictive rules, about 80 percent of family physicians will qualify for the bonus. 

On the downside, the final rule with comment period announces a reduction to payment rates for physicians' services in 2011 under the sustainable growth rate (SGR) formula. The Medicare physician fee schedule rates are currently scheduled to be reduced under the SGR system on Dec. 1, 2010, and then again on Jan. 1, 2011 under current law. The total reduction in rates between November and January under the SGR system will be 24.9 percent. That means the conversion factor will drop from its current $36.8729 to $25.5217 in January, unless Congress and the President intervene. Of course, this week's Congressional election results may impact what happens in this regard, so stay tuned. 

The final rule will appear in the Federal Register on Nov. 29, 2010, and CMS will accept comments on certain aspects of it until Jan. 2, 2011.

Wednesday Dec 23, 2009

A familiar tune

The end-of-year holiday season is upon us.  I can always tell it is because of the displays in the stores, the songs on my radio, and the phone calls I receive asking about the status of next year's Medicare physician fee schedule

Each year about this time, I start getting phone calls from anxious physicians and their staff members asking if the Medicare fees really are going down in January or whether Congress will intervene as it has in the past.  This year is no different.  Under current law, the Medicare conversion factor (which converts relative value units (RVUs) to Medicare payment allowances) is scheduled to decrease by approximately 21 percent for services provided on or after Jan. 1, 2010.  That decrease will be partially offset by RVU increases announced for office visits and other evaluation and management services that family physicians frequently perform, but Medicare fees will still decline significantly if the conversion factor goes down. 

For the past several years, Congress has intervened at the last minute (or sometimes after the last minute) to either freeze the conversion factor or increase it slightly (although the increase is always less than the rate of inflation, so physicians still lose).  The expectation and hope is that Congress will do so again this time around.  For instance, as I write this, the U.S. House of Representatives' Rules Committee has produced a Defense appropriations bill that includes, among other things, a provision to extend the current Medicare physician payment rates through the end of February, with the expectation that this extension will give Congress enough time to enact  health reform legislation that includes a longer-term fix to Medicare's Sustainable Growth Rate (SGR) and physician fee schedule issue.  It's probably appropriate that the extension is attached to a Defense appropriations bill, since physicians would likely be up in arms if Medicare rates actually fell 21 percent. 

In the meantime, the fact remains that Medicare fees will drop in January unless Congress intervenes, which it has not completely done yet.  So, what's a physician to do?  Well, the good folks at the Centers for Medicare and Medicaid Services have given you until Jan. 31, 2010 to decide.  That's when the current period for changing your Medicare participation status for 2010 will end.  For more information,  I would encourage you to visit the Medicare participation options web page on the American Academy of Family Physicians' web site

And with that, I'll return to listening to the radio, where I can almost hear the Congressional Tabernacle Choir singing:

God rest ye merry gentlefolk; let nothing you dismay.

We plan to patch the SGR, and not to cut your pay.

Then do it all again next year, lest you should go astray.

So our tidings of comfort to the annoyed, to the annoyed.

So our tidings of comfort to the annoyed!

Thursday Dec 03, 2009

CMS issues a temporary cease fire

As a follow-up to my last posting ("Medicare shoots first and asks questions later," Nov. 19), I wanted to let readers know that the Centers for Medicare and Medicaid Services (CMS) announced on Nov. 23 that it would delay implementation of new rules that give Medicare the authority to reject claims for services or supplies when the ordering physician or health care professional is not enrolled in the Medicare Provider Enrollment, Chain, and Ownership System, or PECOS. The agency is delaying implementation of the new policy until April 5, 2010.  According to CMS, an extension of the implementation date will give physicians and other health care providers sufficient time to enroll or, if necessary, re-enroll in Medicare.  CMS has indicated that more detailed information about the rules delay will be published soon in MLN Matters, an online publication that is part of CMS's Medicare Learning Network.   

Interestingly, CMS's announcement came just a week after the American Academy of Family Physicians, the American Medical Association, and more than 50 other medical organizations sent a letter to CMS Acting Administrator Charlene Frizzera expressing concerns about the policy.  Among other things, the letter asked for an indefinite suspension of CMS's plans.  While April 5 does not constitute an "indefinite" suspension, it does suggest that CMS is listening and that collective advocacy on the part of organized medicine can have an impact.  When it comes to Medicare, one must take comfort where one can find it.

So, if you or other health care professionals who refer to you are not yet in PECOS, you have been granted a reprieve.  Just remember that a reprieve is not a pardon, and CMS will resume shooting on April 5, 2010.  In the meantime, to quote an old adage, "Forewarned is forearmed."

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