On Wednesday, December 19, the House passed S.B. 2499, the Medicare, Medicaid and SCHIP Extension Act of 2007 by a vote of 411 to 3. In the last few hours of the 2007 legislative session, the U.S. Congress passed a law that postponed for six months the 10.1% cut in the Medicare conversion factor that was slated to occur on Jan. 1, 2008. This law also provides for a 0.5% increase in the conversion factor from January through June 2008.
The following is a summary of the legislation that passed both the Senate and the House. Key elements include. This information will give you the 2008 Medicare physician payment rates and what to expect in your practice during 2008.
The conversion factor change is not the only change affecting 2008 Medicare payment rates. Payment changes will vary by service, specialty and locality based on the following factors:
This year will be the second of a four-year transition to revised practice expense relative value units.
A number of services have revised relative value units for physician work. This change particularly affects anesthesiology, home health and eye exam services, which increase significantly.
The budget neutrality adjustment created last year to adjust for changes from the 5-year review of work values has been increased, which will decrease payments for most services by about one percent.
The geographic adjustment factors have been updated, as they are every three years. The magnitude of the geographic changes is generally small but it affects many payment localities. In addition, the law just passed by Congress continued the floor on the work GPCI and the physician scarcity area bonuses until June 2008.
Some services have been added to those that are subject to imaging payment cuts stemming from the Deficit Reduction Act of 2005 which limits payments to no more than the comparable payment in hospital outpatient departments.
The combined impact of these various payment changes on your practice depends on your specialty, location and service mix. When all of the changes are averaged out across all physicians, there should be a slightly positive increase in rates, but many physicians will see net decreases in payments.
Many other payers as well as Medicare Advantage plans link their rates to the Medicare rates in some way. No information is available about how other payers plan to adjust their rates in response to the six-month intervention by Congress.
For 45 days at the end of each year, physicians have an opportunity to notify Medicare whether they will be a "participating" or a "non-participating" physician in the coming year. Participating physicians agree to accept assignment on all their Medicare claims. Non-participating physicians can make assignment decisions on a claim-by-claim basis. Medicare payment rates for non-participating physicians are 5 percent lower than payment rates for participating physicians, but non-participating physicians can balance bill patients for more than the Medicare rate, up to a "limiting charge" amount.
Physicians also have the ability to "opt out" of Medicare and privately contract with their patients, but neither they nor their patients can submit any claims to Medicare for their services for a two-year period.
Because Congress acted very late in the session to prevent a 10.1% Medicare pay cut, Medicare has indicated that it will be reopening the participation decision period for an additional 45 days. With a 10 percent cut looming in the middle of the year, the participation decision is more complicated. While it is possible that the participation period decision will be re-opened at that time, there is no guarantee. Visit www.ama-assn.org for a document that describes the various Medicare participation options.
There are three Medicare contractual options for physicians. Physicians may sign a PAR (participation) agreement and accept Medicare's allowed charge as payment in full for all of their Medicare patients. Alternatively, they may elect to be a non-PAR physician, which permits them to make assignment decisions on a case-by-case basis and to bill patients for more than the Medicare allowance for unassigned claims. Lastly, they may become a private contracting physician, agreeing to bill patients directly and forego any payments from Medicare to their patients or themselves.
Physicians who wish to change their status from PAR to non-PAR or vice versa will need to do so before Jan. 1, 2008. Once made, the decision will be binding throughout calendar year 2008 except where the physician's practice situation has changed significantly, such as relocation to a different geographic area or a different group practice. To become a private contractor, physicians must give 30 days notice before the first day of the quarter the contract takes effect. Those considering a change in status should first determine that they are not bound by any contractual arrangements with hospitals, health plans or other entities that require them to be PAR physicians. In addition, some states have enacted laws that prohibit physicians from balance billing their patients.
Participation
PAR physicians agree to take assignment on all Medicare claims, which means that they must accept Medicare's approved amount (which is the 80 percent that Medicare pays plus the 20 percent patient copayment) as payment in full for all covered services for the duration of the calendar year. The patient or the patient's secondary insurer is still responsible for the 20% copayment but the physician cannot bill the patient for amounts in excess of the Medicare allowance. While PAR physicians must accept assignment on all Medicare claims, Medicare participation agreements do not require physician practices to accept every Medicare patient who seeks treatment from them.
Medicare provides several incentives for physicians to participate:
The Medicare approved amount for PAR physicians is 5 percent higher than the Medicare approved amount for non-PAR physicians
Directories of PAR physicians are provided to senior citizen groups and individuals who request them.
Carriers provide toll-free claims processing lines to PAR physicians and process their claims more quickly.
Non-participation
Medicare approved amounts for services provided by non-PAR physicians (including the 80 percent from Medicare plus the 20 percent copayment) are set at 95 percent of Medicare approved amounts for PAR physicians, but non-PAR physicians can charge more than the Medicare approved amount.
Limiting charges for non-PAR physicians are set at 115 percent of the Medicare approved amount for non-PAR physicians. However, because Medicare approved amounts for non-PAR physicians are 95 percent of the rates for PAR physicians, the 15 percent limiting charge is effectively only 9.25 percent above the PAR-approved amounts for the services.
With a 10 percent cut about to be imposed, many physicians may consider balance billing an extra 9 percent as one means of helping close the gap between 2007 and 2008 payment amounts. When considering whether to be non-PAR; however, physicians should consider whether their total revenues from Medicare, including amounts the program pays, patient copays and balance billing, would exceed their total revenues as PAR physicians, particularly in light of collection costs, bad debts, and claims for which they do accept assignment. The 95 percent payment rate is not based on whether physicians accept assignment on the claim, but whether they are PAR physicians. When non-PAR physicians accept assignment for their low-income or other patients, their Medicare approved amounts are still 95 percent of the approved amounts paid to PAR physicians for the same service. Non-PAR physicians would need to collect the full limiting charge amount roughly 35 percent of the time they provide a given service in order for the revenues from the service to equal those of PAR physicians for the same service. If they collect the full limiting charge for more than 35 percent of the services they provide, their Medicare revenues will exceed those of PAR physicians.
Assignment acceptance, for either PAR or non-PAR physicians, also means that the Medicare carrier pays the physician the 80 percent Medicare payment. For unassigned claims, even though the physician is required to submit the claim to Medicare, the program pays the patient, and the physician must then collect the entire amount for the service from the patient.
Private contracting
Provisions in the Balanced Budget Act of 1997 give physicians and their Medicare patients the freedom to privately contract to provide health care services outside the Medicare system. However, private contracting decisions may not be made on a case-by-case or patient-by-patient basis. Once physicians have opted out of Medicare, they cannot submit claims to Medicare for any of their patients for a two-year period.
Private contracts must meet specific requirements:
The physician must sign and file an affidavit agreeing to forego receiving any payment from Medicare for items or services provided to any Medicare beneficiary for the following two-year period (either directly, on a capitated basis, or from an organization that received Medicare reimbursement directly or on a capitated basis);
Medicare does not pay for the services provided or contracted for;
The contract must be in writing and must be signed by the beneficiary before any item or service is provided;
The contract cannot be entered into at a time when the beneficiary is facing an emergency or an urgent health situation.
In addition, the contract must state unambiguously that by signing the private contract, the beneficiary:
Gives up all Medicare payment for services furnished by the "opt out" physician;
Agrees not to bill Medicare or ask the physician to bill Medicare;
Is liable for all of the physician's charges, without any Medicare balance billing limits;
Acknowledges that Medigap or any other supplemental insurance will not pay toward the services; and
Acknowledges that he or she has the right to receive services from physicians for whom Medicare coverage and payment would be available.
To opt out, a physician must file an affidavit that meets the above criteria and is received by the carrier at least 30 days before the first day of the next calendar quarter. There is a 90-day period after the effective date of the first opt-out affidavit during which physicians may revoke the opt-out and return to Medicare as if they had never opted out.
This document contains excerpts from the AMA-published Medicare RBRVS: The Physicians' Guide 2007. The complete guide is available from AMA Press by calling toll free (800) 621-8335.
Have you registered for the 2008 Mid-Winter Conference and the Physician Practice Seminars that are scheduled for the weekend event January 25-27, 2007? Click here for the conference brochure and registration form.
A new addition to the Mid-Winter Conference is a special all day seminar on Friday, January 25th, for physicians, office managers, medical assistants and other office personnel. The morning session will include a workshop on front office skills, designed to enhance your medical practice by maximizing the professionalism of your staff. Some of the topics to be discussed include telephone etiquette, billing and collections, effective communication between staff members and patients, time management and teamwork. The WVSMA is bringing in a nationally known consultant to conduct this special session. Any staff member in your office who has contact with patients should plan to attend this seminar. Attendees will not only enhance their customer service skills during the session, but they will also learn basic principles that can help reduce the risk and liability associated with staff/patient interactions.
The Friday afternoon session will include a payor workshop with major payors, both government and commercial, participating. This will be an excellent opportunity to learn about the 2008 changes that various payors have implemented. There will also be time available to network with the payor representatives.
An additional physician practice seminar will be held on Saturday afternoon, January 26, to acquaint physicians and staff with some of the new Medicare Advantage plans. In an attempt to educate physicians about the changes and in turn assist you with educating your patients, the WVSMA has decided to provide a special physician advocacy session for physicians during the Mid-Winter Conference. Payor reps from the various Medicare Advantage plans will be presenting and addressing your issues and concerns.
During the session, physicians will learn all about the Medicare Advantage Private Fee For Service Plans (PFFS) from management and representatives of each plan. They will learn the terms and conditions of participating in each plan so that they may better educate their patients about plan requirements. Patients will benefit from this session because the physician will be much more knowledgeable and aware about the PFFS plans.
Make plans and reservations now for these special seminars. For additional information, you may contact the WVSMA at (304) 925-0342, or visit our website www.wvsma.com.
All written prescriptions for Medicaid recipients will soon be required to be written on mandated tamper resistant prescription pads in order to be eligible for reimbursement. This action is required by section 7002(b) of the U.S. Troop Readiness, Veterans' Care, Katrina Recovery, and Iraq Accountability Appropriations Act of 2007, which was signed into law on May 25, 2007. There have been many questions within the physician community about the prescription pad requirements, particularly in light of the cost of securing the new prescription pads.
The original date for implementation of this law was October 1, 2007, but in order to allow adequate time for physicians to comply with the new requirements, the initial compliance date was changed to April 1, 2008. Effective for dates of service on and after April 1, 2008, a prescription pad must contain at least one of the following characteristics:
1. Industry-recognized features (s) designed to prevent unauthorized copying 2. Industry-recognized feature (s) designed to prevent erasure or modification of information written by the prescriber, or 3. Industry-recognized feature (s) designed to prevent use of counterfeit prescription forms
Effective for dates of service on and after October 1, 2008, a prescription pad must contain all three of the characteristics in order to be tamper resistant.
According to the ruling, physicians who use computer generated prescriptions for Medicaid patients will also need to ensure that the paper being used in the printer is compliant and tamper resistant as of that date.
The DEA (Drug Enforcement Administration) and the WV Board of Pharmacy laws and regulations pertaining to written and electronic prescriptions for drugs still apply. The WVSMA has been informed that WV Medicaid will not purchase the pads for physicians nor will they endorse specific vendors. In other states, tamper resistant pads have been proven to help make communities safer by implementing an effective prescription fraud prevention program. They also have significantly reduced the costs being absorbed by commercial payors for fraudulent drug abuse.
Physicians have indicated that although the TRPP requirement is for Medicaid recipients, they will most likely use the tamper resistant prescription pads for all patients, which will impact their practice budgets.
As always, the WVSMA will continue to research this issue in order to keep physicians updated and informed as to any changes that may come prior to the implementation date of October 1, 2007.
CMS and WVSMA want to issue a reminder to offices that the NPI Requirement on Medicare Electronic and Paper Institutional Claims Begins 1/1/08!
Effective 1/1/08, NPIs will be required to identify the primary providers (the Billing and Pay-to Providers) in Medicare electronic and paper institutional claims (i.e. 837I and UB-04 claims). Physicians may continue to use the legacy identifier in these fields as long as you also use the NPI in these fields. This means that 837I and UB-04 claims with ONLY legacy identifiers in the Billing and Pay-to Provider fields will be rejected starting on 1/1/08. (Pay-to Provider is identified only if it is different from the Billing Provider.)
You may continue to use only legacy identifiers for the secondary provider fields in the 837I and UB-04 claims, until 5/23/08, if you choose.
Urgent: Test Your Claims Now!
After you have submitted claims containing both NPIs and legacy identifiers and those claims have been paid, Medicare urges you to send a small batch of claims now with only the NPI in the primary provider fields. If the results are positive, begin increasing the number of claims in the batch.
(Reminder: For institutional claims, the primary provider fields are the Billing and Pay-to Provider fields. For professional claims, the primary provider fields are the Billing, Pay-to, and Rendering Provider fields. If the Pay-to Provider is the same as the Billing Provider, the Pay-to Provider does not need to be identified.)
What To Do If Your Claims Are Rejecting
If you are submitting an NPI and a legacy identifier pair on your claims and they are being rejected first go into the NPPES website located at https://nppes.cms.hhs.gov/ and validate that your NPPES information is correct and that you reported your Medicare legacy identifier in the appropriate Medicare sections of the "Other Provider Identification Numbers" field. Your Medicare legacy identifier is the identifier that Medicare assigned to you upon enrollment.
Sometimes Medicare assigned multiple identifiers to a single provider. Usually this occurred because the provider has multiple locations or if the provider is an individual and works in multiple locations. An enrolled physician/non-physician practitioner and the group practice to which the physician/non-physician practitioner assigns his/her benefits would both have unique legacy identifiers. Legacy identifiers are the ones that were used prior to using NPIs to identify Billing/Pay-to and Rendering Providers.
If the information in your NPPES record is correct and contains your Medicare legacy identifier(s), print the screen (so you have a copy of this portion of your NPPES record on paper), call your Medicare contractor, and ask that they confirm that this information is present in the Medicare NPI Crosswalk. If your contractor confirms you are not on the crosswalk, please ask them to validate what information they have in their provider file.
In an effort to inform our members about your options to protect access to your prescribing information, we want to remind physicians of the American Medical Association's Physician Data Restriction Program (PDRP). You may go to the AMAs web site for more information and to register to protect your information.
The AMA recognizes that the inappropriate use of prescribing data is a growing concern among physicians and has developed the Physician Data Restriction Program to empower physicians. They also believe that restricting access to prescribing data should be every physician's individual choice.
The AMA's Physician Data Restriction Program (PDRP) provides physicians a choice while ensuring that vital information on prescribing patterns continues to be available for beneficial public health purposes. Some of these include evidence-based medical research, structuring clinical trials, efficient drug recalls, aiding the FDA's ongoing post-approval assessment of drug benefits vs. risks, and many other uses.
Collecting prescribing data can also benefit physicians by providing them with a self-evaluative tool Therapeutic Insights that helps them compare prescribing data to evidenced-based guidelines.
While the AMA does not collect, compile, license, sell or have access to physician prescribing data, it does offer individual physicians a choice in how their prescribing data are used. For over a century, the AMA has been recognized as a trusted source of physician practice, licensure, and medical education data. The AMA licenses these data to prevent fraud and abuse, for physician manpower planning, to verify physician credentials in accordance with the standards of accreditation organizations and by government officials during times of national disaster like Sept. 11th and Hurricane Katrina.
Physician professional data are also licensed to Healthcare Organizations (HIOs) who append prescribing data to the data they license from the AMA for use by pharmaceutical companies. Although the AMA licenses physician practice data to the HIOs, these organizations have multiple sources of physician data independent of the AMA that enable them to collect and license prescribing data without licensing AMA data.
The fact that AMA data are utilized by the HIOs enables the AMA to exert regulations on how physician data are used as well as offer programs such as the PDRP which empowers physicians. Compliance with such programs is mandated through AMA licensing agreements.
At the end of the year, physician practices typically receive an increased number of fax requests for copies of the practice's or physician's W-9, National Provider Identifier or other information that allow a payer to process your claims or update its physician roster. While these fax requests may be legitimate, other unsolicited requests may only be masquerading as a proper request for information and may in fact, bind you unknowingly to a contract with a provider network or other entity. Be sure to instruct your staff to read all faxes carefully. The physician or legal representative should carefully review and understand any agreement or contract before signing.
If your practice receives an unsolicited fax request from an unknown party, please forward the information to Barbara Good, Physician Practice Advocate, via fax (925-0345) or email (Barbara@wvsma.com).
During the period from July 1, 2007 through December 31, 2007, physicians who reported on quality measures included in the PQRI became eligible to receive a bonus of 1.5 percent of their total Medicare allowed charges for that six-month period. The bonus payments will be made as a lump sum payment sometime after February 2008.
The new law just passed by Congress extends this program for an additional year. Physicians who participate in the PQRI from January through December 2008 will be eligible to receive a bonus of 1.5 percent of their total Medicare allowed charges for the year 2008 as a lump sum payment sometime after February 2009. Visit www.ama-assn.org for more information about the measures used in the PQRI program and how to report them.
The Unisys call center will be closed on Monday, December 24th, and Tuesday, December 25th, as well as Monday, December 31st, and Tuesday, January 1st. Normal operating hours will resume on Wednesday, December 26th and Wednesday, January 2nd.
Effective on Dates of Service January 1, 2008 and after, if billing for a drug, physicians must bill with the appropriate NDC number. Although the NDC number is not required for Inpatient Services and Immunizations, NDC numbers are required for Radiopharmaceuticals. Physicians may bill these claims electronically through the Web Portal "only for the 837P" and also on paper. The 837I on the Web Portal is currently being configured/developed to accommodate this requirement. For more information regarding NDC, please visit the "NDC Information" section listed under the Documents page.
Effective January 1, 2008, all providers will be required to submit claims on the new CMS 1500, UB04 and ADA 2006 forms. Claims will be returned back to the provider if submitted on the old billing forms after 1-1-08. Please refer to the updated billing instructions on the website for correct billing procedures.
Modifications have been made to the eligibility transaction on the Webportal. Those modifications will now report if a Medicaid Member is participating in the Basic or Enhanced benefit.
Unisys and the Bureau for Medical Services (BMS) will be conducting six Provider Workshops throughout the State to discuss NPI, Plastic ID Cards, MR/DD Waiver changes, NDC requirements and general billing updates. The
