The spring of 2013 has certainly had its share of ups and downs so far. Although Congress reversed the devastating 26.5 percent Medicare payment cuts in early January, physicians weren’t out of the woods concerning reimbursement — mandatory across-the-board cuts brought about by federal sequestration reduce reimbursement by two percent on all Medicare physician claims with a date of service on or after April 1. If you don’t think that sequestration will affect you, think again. Even non-participating physicians are being hit. You’ll see it on Medicare remittances, which now reveal a code – CR233 “Adjustment code for mandated Federal, State or local law/regulation that is not already covered by another code and is mandated before a new code can be created” – for the sequestration cuts.
The two percent adjustment is only to be applied to the Medicare portion of payments, not the allowed charge, and does not affect beneficiaries’ financial responsibility. In other words, the 80 percent of your Medicare reimbursement paid by the program is two percent lower, but the amount you are to collect from patients — the 20 percent coinsurance and any deductible amount — is still based on the full allowed charge before the two percent cut. That works out to a 1.6 percent reduction on claims where the patient is financially responsible.
And that’s not all. If your reporting period for the government’s electronic health record (EHR) meaningful use program began on or after April 1, your incentive check also will be hit by sequestration’s two percent cuts.
On the bright side, after several months of anxious anticipation, the Medicaid rate parity created by the Patient Protection and Affordable Care Act of 2010 has finally started to bear fruit. For a period of 24 months — January 1, 2013 through December 31, 2014 — all primary care physicians, as well as many non-surgical specialists, who participate with Medicaid will receive rates at or above Medicare levels for evaluation and management (E/M) codes. The increased rates will also apply to reimbursement for vaccine administration. Intended to be effective on January 1, CMS issued a Federal Rule in November 2012 instructing the states to submit their plans for implementing the new rates by March 31, 2013. Naturally, if you tell a state Medicaid program it does not have to submit a plan until the spring, it should come as no surprise to see many states taking it right down to the wire. Those plans had to be reviewed at the federal level before the parity money could start flowing to physicians. But, as we begin May, it’s exciting to see physicians starting to receive their enhanced payments. In light of research that reveal some 44 of the 50 states with Medicaid rates below those of Medicare — some with payments as paltry as New York Medicaid’s 36 cents on the Medicare dollar – this provision of the Affordable Care Act will produce significant rewards for many physicians who treat Medicaid patients. Despite the hiccup in the initiation of the program, states must pay physicians retroactively to January 1, 2013. While it’s good news, my experience shows that states will not move at lightning speed nor will they attempt to streamline the application process for this important program. In fact, many are requiring an application process like this one that Missouri requires of physicians. The Medicaid parity program is only in place for two years, so don’t let this one slip by. Click here for more information.
Another recent success in the physician reimbursement landscape has been the number of practices receiving extra money from insurers for becoming patient-centered medical homes for their patients. This additional reimbursement typically comes in the form of care management fees that average $3 per member per month or enhanced reimbursement of up to five percent applied to fee-for-service rates. The money isn’t arriving on a silver platter, however. Successful practices are seeking national recognition as patient-centered medical homes and proactively requesting payers to reward them for it. The upticks in payment are adding up to significant dollars for primary care practices, which can participate in one of four nationally recognized programs for medical homes. Specialty practices also have a way to get in the game thanks to the March 25, 2013 launch by the NCQA of its Patient-Centered Specialty Practice recognition program.
Challenges will certainly abound as 2013 unfolds, but don’t get discouraged and sit on the sidelines. Gain knowledge — and stay strong.