Category Archives: Medicare & Reimbursement

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Pennsylvania Workers Compensation Prescription Drug Reimbursement Restrictions

On October 27, 2014, the Governor signed Pennsylvania General Assembly enacted House Bill 1846, which limits both the authority and the reimbursement of physicians and providers other than pharmacies for prescription drugs.  It provides as follows: Physicians dispensing prescription drugs from their offices shall receive no more than 110% of the original average wholesale price … Continue Reading

Face-to-Face Medicare Reimbursement Requirements for Home Health Certification

CMS has announced its concern regarding the level of compliance for documenting the face-to-face elements necessary for home health care certification. Attached is an educational piece published by Novitas Solutions on its Part B website. It lists the qualification criteria for home health benefits: Be confined to a home; Under the care of a physician; … Continue Reading

CMS Seeking Comments Regarding Expanding Coverage for Secondary Interpretation of Images

In the proposed 2015 Medicare Physician Fee Schedule, CMS is seeking comments regarding expanding coverage for secondary interpretation of diagnostic imaging. I’m enclosing pages 40370 and 40371 of the proposed Medicare Physician Fee Schedule. The enclosed material sites the Medicare Claims Processing Manual provisions which make is clear that a professional component interpretation service should … Continue Reading

CMS Designates Global Surgery as “Potentially Misvalued Services”

In the recently proposed 2015 Physician Fee Schedule, CMS devoted significant resources to discussing potentially misvalued services, which I believe is code for places where CMS would like to reduce reimbursement. One of the areas is global surgery fees. CMS has concerns with the 10 and 90 day global surgery fees because these global packages … Continue Reading

CMS Releases Proposed 2015 Physician Fee Schedule and Projects 20.9% SGR Reduction

CMS has issued the Proposed 2015 Physician Fee Schedule and Fact Sheets for specific issues (ASC, ESRD, Home Health, Physician Quality Programs). SGR Reduction Although the Protecting Access to Medicare Act Prohibits any SGR reduction for the first 60 days of 2015, i.e., until March 1, 2015, CMS predicts a 20.9% decrease without legislative action. … Continue Reading

CMS Releases 2012 Physician Payment Data; WSJ Allocates by Specialty

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html http://online.wsj.com/news/articles/SB10001424052702303456104579490043350808268?mod=djemalertNEWS   The 2 links above should connect you to the total physician payment information by individual and specialty.  … Continue Reading

MGMA Special Alert – SGR Repeal

March 31, 2014 – Special Alert:   Senate approves House-passed SGR patch Today, by a vote of 64-35, the Senate agreed to legislation passed by the House of Representatives, H.R. 4302, which delays for one year a 24% cut to Medicare physician payments resulting from the sustainable growth rate (SGR) formula. The legislation is expected to … Continue Reading

Latest SGR Repeal News from MGMA

March 27, 2014 – Special Alert   House passes one-year SGR patch  Today the House of Representatives passed by voice vote H.R. 4302, which would temporarily delay the 24% cut to Medicare physician payments resulting from the sustainable growth rate (SGR) formula for one year. MGMA has joined with physician organizations in Washington to continue … Continue Reading

Practical considerations to protect against being ‘out of network’

Practical considerations to protect against being ‘out of network’ The disengagement of Highmark and UPMC is looming on the horizon; most of the hospital participation agreements between these two competing healthcare systems end on December 31, 2014.  There are some hospital agreements that continue, such as those at Children’s and Magee, but the focus of … Continue Reading

Congress Passes 3 Month SGR Reprieve: .5% Medicare Physician Increase

The AMA Wire reports the following action on the Medicare Physician Fee Schedule:   *3-month Medicare payment update approved for Jan. 1 *Congress has adopted a 0.5 percent update to Medicare payments for three months, following a bipartisan vote of 64 to 36 in the U.S.  Senate         Wednesday afternoon. *The president is expected to sign … Continue Reading

SGR Update

I recently posted the SGR White Paper published jointly by the Senate Finance Committee and the House Ways and Means Committee. Earlier this week, both committees endorsed legislation enacting those concepts. The section by section summary of the SGR Repeal and Medicare Beneficiary Access Improvement Act of 2013 is attached. Unfortunately, both the House and … Continue Reading

Joint House and Senate SGR White Paper Proposes Permanent SGR Repeal

The House Ways and Means Committee and the Senate Finance Committee have jointly issued a White Paper proposing the repeal of the Medicare Sustainable Growth Rate Formula, entitled “SGR Repeal and Medicare Physician Payment Reform”. The SGR white paper acknowledges that the Sustainable Growth Rate formula is “fundamentally broken” and that application of the SGR … Continue Reading

CMS Proposes 2014 Medicare Physician Fee Schedule; SGR Reduction Projected @ 24.4%

CMS has issued the poroposed Medicare Physician Fee Schedule. Without Congressional intervention, the SGR will mandate a 24.4% decrease. CMS sent its calcuations to the Medare Payment Advisory Commission.   http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SustainableGRatesConFact/Downloads/SGR2013-Final-Signed.pdf CMS has also issued a Fact Sheet Summary:   http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-07-08.html?DLPage=1&DLSort=0&DLSortDir=descending… Continue Reading

DME Face-to-Face Delayed Until October 1, 2013

Additional Time to Establish Protocols for Newly Required Face-to-Face Encounters for DME Due to concerns that some providers and suppliers may need additional time to establish operational protocols necessary to comply with face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for certain items of Durable Medical Equipment (DME), CMS will start actively enforcing … Continue Reading

National Commission on Payment Reform Recommends 5 Year Transition Model

The Society of General Internal Medicine convened the National Commission on Payment Reform to formulate a recommendation for healthcare payment reform. This Commission released its Report in March 2013. Although we have attached the report, here are the 12 fundamental recommendations. 1.         Over time, payers should largely eliminate stand-alone fee-for-service payment to medical practices because of its … Continue Reading

CMS Implements 0% Medicare Payment Update: Hold Claims for 10 Day

The American Taxpayer Relief Act of 2012 includes the Physician Update Fix, which essentially provides a 0% Medicare change for 2013. The Centers for Medicare & Medicaid Services (CMS) is currently revising the 2013 Medicare Physician Fee Schedule (MPFS) to reflect the new law’s requirements as well as technical corrections identified since publication of the final … Continue Reading

OIG Approves Per Diem Call Pay

OIG Advisory Opinion No. 12-15 has approved an existing arrangement under which a hospital pays physicians a per diem fee for providing on call ER coverage. Under the arrangement, the hospital pays per diem fees to 130 specialty physicians on staff who provide on-call services, including: ·         telephone consultations; ·         in-person consultations, as well as … Continue Reading

2013 Medicare Physician Fee Schedule

The Centers for Medicare & Medicaid Services (CMS) finalized the Medicare physician fee schedule for 2013. Unless Congress intervenes, the rule implements a 26.5 percent reduction in Medicare physician payments in 2013 based on the sustainable growth rate (SGR) formula. MGMA will continue its steadfast advocacy efforts to repeal the flawed SGR formula, and we … Continue Reading

THE PROPOSED 2013 MEDICARE PHYSICIAN FEE SCHEDULE PRESENTS SOME MAJOR CONCERNS

CMS issued the proposed 2013 Medicare Physician Fee Schedule on July 30, 2012. The complete document package of approximately 700 pages is available on both the CMS website and at www.medlawblog.com. For this article, I will not summarize all 700 pages, but I would like to hit three of the most significant issues: 1.   27% proposed … Continue Reading

CRNA – CMS Developments

  I thought you might be interested in linking to or writing about a recent blog post by Christine Zambricki, a top official with the American Association of Nurse Anesthetists. The post originally appeared in ADVANCE for Nurses Protecting Access to CRNAs Relieves Patient Pain By Christine Zambricki, CRNA, MA, FAAN In less than two weeks, … Continue Reading

Colorado State Court Rules CRNAs May Practice Without Physician Supervision

In Colorado Medical Society v. Hickenlooper, a Colorado appeals court ruled the state of Colorado may op-out of the CMS rules requiring physician supervision of CRNAs in hospitals, ambulatory surgery centers, and critical access hospitals.  The case is actually about the Medicare regulations for hospital participation, but it is based upon the concept of private … Continue Reading
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