Few discussions of health care reform, i.e. the Patient Protection and Affordable Care Act (PPACA) occur without mentioning the fact that the legislation exceeded 2,000 pages, therefore, a summary of the provisions that directly affect your reimbursement and your practice structure and health care coverage obligations might be helpful. 


1.         Physician Fee Schedule

(a)        The 21.3% SGR reduction has been delayed only until May 31, 2010.

(b)        Medicaid primary care physician fees must be 100% of Medicare in 2013 and 2014; no provision made thereafter.

 2.         Physician “Whole Hospital” Ownership Stark Exception

Physician owned hospitals are protected by grandfather provisions of PPACA if physician ownership established prior to December 31, 2010 and not changed after March 23, 2010, and provided no change in the number of licensed beds after March 23, 2010.

3.         Medicare Self-Referral Disclosure Protocol

PPACA § 6409 requires HHS to develop a Medicare self-referral disclosure protocol on or before September 23, 2010.

4.         Special Requirements for DME and Home Health Services

(a)        Effective July 1, 2010, ordering physicians must be enrolled in Medicare.

(b)        Physicians providing Home Health and DME services must maintain records of referring physicians.

(c)        Effective January 1, 2010, physicians certifying the medical necessity of Home Health and DME must have concluded face-to-face patient encounters, or some approved alternative.

5.         Registration of Billing Agents, Clearinghouses and Alternate Payees

PPACA § 6503 requires all billing agents, clearinghouses and alternate payees to be registered with CMS by December 31, 2010, in accordance with procedures to be announced. A comparison provision, § 6505, prohibits Medicaid payments to institutions or entities located outside of the U.S.

6.         Physician Quality Reporting Initiative (PQRI)

(a)        PQRI extended through 2014 and incentive payment increased by .5% for 2011 through 2014. Penalty provision of 1.50% reduction for non-participation kicks in in 2015.

(b)        CMS to develop Physician Compare Website by January 1, 2011.

7.         PPACA Reduces Medicare FFS Claim Filing Period to One Year.

PPACA § 6404 amends the timely filing requirements to reduce the maximum time period for submission of all Medicare FFS claims to one calendar year after the date of service. Under the new law, claims for services furnished on or after January 1, 2010, must be filed within one calendar year after the date of service. In addition, § 6404 mandates that claims for services furnished before January 1, 2010 must be filed no later than December 31, 2010. The following rules apply to claims with dates of service prior to January 1, 2010. Claims with dates of service before October 1, 2009, must follow the pre-PPACA timely filing rules. Claims with dates of service October 1, 2009 through December 31, 2009 must be submitted by December 31, 2010. For more details on this, see:



1.         Employers with 50 or more employees who do not offer coverage must pay $750 per FTE penalty. Individuals must obtain minimum essential coverage starting in 2014. The penalties for individuals will be:

            (a)        2014 – $95

            (b)        2015 – $325

            (c)        2016+ – $695

2.         Employers with 50 or more employees who do not provide coverage, but apply waiting periods will pay penalty starting 2014:

(a)        30-60 days — $400 per FTE

(b)       60-90 days — $600 per FTE

3.         Flexible Spending Account contributions are capped at $2,500 starting 2013.

4.         The “Cadillac health plan” tax would be imposed starting 2018, with the thresholds of $8,900 for individual plans and $24,000 for family plans.

5.         Dependent coverage for all children until age 26 (regardless of statement or dependent status) and exclusions of children with pre-existing conditions prohibited effective for plan years beginning on or after September 23, 2010.

6.         Mandatory minimum benefit package will be developed to be effective January 1, 2014.

7.         Discrimination in benefit packages based on wages prohibited effective September 23, 2010.

8.         Small business tax credits for providing health care coverage begin in 2010. For these calculations, you should consult your accountants.

9.         Beginning in 2010, employers must report the value of health care benefits on employees’ W-2s.



1.         Center for Medicare and Medicaid Innovation to be established by January 1, 2011.

2.         HHS directed to develop Medicare Shared Savings Program and Accountable Care Organizations by January 1, 2012.

3.         HHS to develop national voluntary bundled payment plot pilot programs by January 1, 2013.

4.         There is no provision for tort reform.



It is ironic that the two most pressing questions regarding health care have vastly different timeframes. Relief from the Medicare Sustainable Growth Rate 21.3% fee schedule reduction extends only until May 31, 2010, at least at the time of the printing of this article. Congress neutralized the SGR reduction every year for the last five years and three times in the last five months. Obviously, a permanent fix of this issue is absolutely essential, and no one is guaranteeing that the permanent fix will mean maintenance of the status quo. Conversely, Medicare reform in the form of accountable care organizations, medical homes, and pay for performance are all pie in the sky at this point. The only thing PPACA does is create commissions to study the issue.