The 2010 proposed physician fee schedule for Medicare includes a number of changes in physician reimbursement, most notably an across the board 21.2% cut to the conversion factor.  This is due in part to several major changes to the practice-expense portion of the relative value unit (RVU) system that determines reimbursement for individual services, along with more minor changes to the work and liability RVUs.   Since all changes must be budget-neutral, the results are expected to be modest increases for physicians in primary care but larger reductions in average pay for some other specialists.

The WVSMA has joined the AMA in encouraging Congress to correct major weaknesses in the structure of the Medicare program and enact stable, adequate annual Medicare physician payment updates.

Listed below are some of the specialties seeing the biggest increases and the biggest hits in total 2010 payments.

Specialty                                                   Average change

Ophthalmology                                      5%
Family medicine                                    4%
General practice                                    3%
Geriatrics                                                3%
Internal medicine                                  2%
Interventional radiology                       -3%
Urology                                                   -4%
Radiology                                               -5%
Cardiology                                              -8%
Nuclear medicine                                 -18%

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CMS adopted a new policy for billing consultations in the physician fee schedule final rule which was published in October. Since that time, the AMA has heard from numerous physicians and state and specialty societies opposing the new policy which calls for physicians to bill for consults using the new and established patient codes rather than the consultation codes in the CPT book.  At the recent meeting in Houston, the AMA's House of Delegates passed Resolution 807 which calls for the AMA to oppose the new policy.

Recently, the AMA met with senior CMS staff to discuss the technical, policy, and practical concerns this policy presents. The AMA highlighted for CMS the serious consequences that this policy will have on physicians and their patients if the agency moves forward on January 1, 2010.  In addition, the AMA stressed that the January implementation date was likely to result in substantial confusion and claims processing problems. The AMA is continuing to engage CMS in a discussion on the concerns of this new policy.  New information will be relayed as soon as it is received.

The WVSMA has been requesting information from both commercial and governmental payors as to how they plan to handle the proposed change in the consultation policy.  This information was current as of December 1, 2009.

As of this date, Mountain State Blue Cross Blue Shield has stated that the plan will not be making any changes in their billing and reimbursement policies regarding consults.

PEIA plans to continue to accept the consult codes and reimburse them with the Evaluation and Management allowances.

Aetna will be following their current fee schedule.  The plan does not change the fee schedule in January; instead they wait until September or October to change.  The Aetna fee schedule will remain at 130% of 2009 Medicare.

Per the Director of Claims for the Health Plan of the Upper Ohio Valley, the plan will be following Medicare's new rules as of January, 2010.

Humana has announced that, beginning January 1, 2010, the for Medicare Advantage lines of business these CPT codes (99241-99255) will not be acceptable and will require the most appropriate office visit or hospital inpatient CPT Codes (99201-99215, 99241-99239)

For non Medicare Advantage lines of business the Humana systems will accept either set of codes. 

CIGNA states that since CMS has not eliminated the consultation codes and the 2010 version of RBRVS still contains Relative Value Units for these codes, the plan will still recognize these codes for billing and reimbursement on January 1, 2010.

CIGNA also plans to continue to study the CMS change in conversion factor and will not institute the 21.2% reduction on January 1, 2010.   CIGNA will provide 90 day advance notice to health care professionals on any action taken after a study of the components of the CMS RBRVS 2010 rule.

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As of this date, the new Medicare fee schedule for 2010 is still scheduled to begin on January 1, 2010.  Since many physicians are questioning continuing their participation in the Medicare program, CMS has granted an extension in the enrollment period when physicians may change their participation status.   Included below is information that you should know when considering your participation or non-participation in the program.

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.

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. 31, 2010. Once made, the decision will be binding throughout calendar year 2012 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.

When considering whether to be non-PAR,  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.

For additional information about Medicare participation, you may go to the CMS website (www.cms.gov).  You may also visit the WVSMA website for a document that describes the various Medicare participation options.

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The West Virginia State Medical Association will hold the 2010 Annual Business Meeting and Physician Practice Management Conference from Friday, January 29th – Sunday, January 31st at the Charleston Marriott Hotel.
 
This year’s meeting will begin with a Physician Practice Conference on Friday, January 29th.   The day’s schedule includes sessions on Management Tips for a Profitable Practice, CPT 2010 Coding Updates and Revisions, a RAC Update from Connolly Consulting, Medical Etiquette/Protocol, and Payor Updates focusing on all the changes for 2010.

In the past, these popular conferences have provided a wealth of information so you’ll want to register early.  The conference is geared toward both physicians and their staffs.

On Saturday, a full schedule is planned, including the WVSMA First Session of the House of Delegates and sessions on the 2010 Legislative Agenda and the Federal Health System Reform.

A special social event is planned at Noon as the WVSMA hosts a WVU vs. Louisville Basketball Game Watching Party.   You’ll want to come and enjoy the fun during this game day special event!

The afternoon will include a choice of breakout sessions focused on topics to enhance your medical practice.  

The business meeting will conclude on Sunday with WVSMA Delegate voting, the election and announcement of the 2010-2011 WVSMA officers, and the Second Session of the House of Delegates.  

Special lodging rates are available at the Marriott from Thursday through Sunday for those attending the conference.  Call (304) 345-6500 to book your reservation.  Be sure to tell them that you are with the WVSMA.

More program details will be coming soon.  Visit us on the web at www.wvsma.com. 
 

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This information was supplied by UniCare Health Plan.

HEDIS is Coming!

Each year, UniCare Health Plan of West Virginia, Inc., Carelink Health Plans and The Health Plan of the Upper Ohio Valley perform medical record data collection as part of HEDIS(r) (Health Care Effectiveness Data Information Set). HEDIS is a nationally recognized quality improvement initiative used by consumers, purchasers, regulators, and the National Committee for Quality Assurance (NCQA) to compare health plans' performance.

Physicians will begin to receive their HEDIS record requests from the different plans beginning in early 2010, along with detailed explanations for submitting information.  Please note that as a contracted provider for one of the aforementioned health plans, it is required that you participate in the HEDIS process.

If you have any questions regarding HEDIS, please contact your local network representative.

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UnitedHealthcare has announced that the healthcare plan will continue to offer coverage of screenings for women under 50

The U.S. Preventive Services Task Force (USPSTF) recently released new guidelines for mammography screening based on a review of the medical literature. As a result of its review, the USPSTF is recommending that regular screening for breast cancer in women begin at age 50. The previously recommended age to begin routine screening was age 40. A number of factors influenced the USPSTF decision, among them a lower incidence of breast cancer in women under age 50 and the resultant relative increase in what are called "false positives".

UnitedHealthcare considers mammography an important screening procedure, one that has resulted in the ability to detect and treat breast cancer at earlier stages of the disease and save lives. Many health and professional organizations such as the American Cancer Society, the American College of Radiology, and the American College of Obstetrics and Gynecology continue to recommend that mammography screening begin at age 40. 

The decision of when to begin screening should be made in consultation with a personal physician.

UnitedHealthcare will continue to offer coverage of screening mammograms for women, including those over the age of 40, when recommended by their physicians.

In addition, ACOG has changed its guidance on cervical cancer screening, recommending less frequent screening for women in their 20s. However, UnitedHealthcare is not changing our coverage for cervical cancer screening. As is true for mammography, we recommend that women discuss with their physicians how frequently they should undergo cervical cancer screening.

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This information is provided by West Virginia Medicaid.

The West Virginia Medicaid Preferred Drug List will be updated effective January 1, 2010.  The complete list is found on the Medicaid website, www.wvdhhr.org/bms. 
 Significant changes are:

• Kadian 80mg and 200mg are non-preferred.  Other strengths remain preferred.

• Depakote ER is non-preferred.  Generic equivalent is preferred.  DAW -1 requests will be approved for diagnosis of seizure disorder when physician writes “Brand Medically Necessary” in his/her own handwriting. (This policy applies to all non-preferred anticonvulsants with seizure disorder diagnosis).

• Effexor XR is non-preferred.  Venlafaxine ER is preferred.  The generic product is not AB rated equivalent and a new prescription is required.  Authorization for Effexor XR (up to 90 days) can be obtained during the transition period upon request to RDTP.

• Lexapro is preferred.

• Januvia/Janumet in combination with insulin will deny.  A call to the helpdesk is required.

• Actos 30mg and 45mg are non-preferred.  Only Actos 15mg is preferred.  Only Actos 15mg is preferred.  Multiple equivalent doses may be dispensed, per the Board of Pharmacy, without a new prescription.

• Actoplus Met is non-preferred.  The separate ingredients – Actos and metformin – are preferred. 

• Avandia, Avandamet, Avandaryl are non-preferred. 

• Veramyst is non-preferred except for children under the age of 12 years.

• Ophthalmic fluoroquinolone antibiotics are non-preferred for members under the age of 21 years.

• Vitamin D list of NDC’s is available on the Medicaid website.

• Effient remains non-preferred.  Members being discharged from hospital post stent placement will be approved upon request.  Pharmacists are encouraged to dispense emergency supplies pending PA requests when appropriate.

• Prevacid is non-preferred.  Nexium and Kapidex are preferred.

Prior authorization may be requested by contacting the Rational Drug Therapy Program at 1-800-847-3859, option 1 then option 2.  Also, as a reminder for pharmacies, a three day emergency supply is available to allow claims to be filled on an emergency basis for a 3 day supply when either the prescriber is not available to provide information for a Prior Authorization (PA) or when PA services are not available by submitting the number 99 in the Submission Clarification Code field (NCPDP field 420-DK).

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A Spring Coding 101 course will be offered by Laura Sullivan, CPC, RMC, PCS, beginning on February 20th and continuing for 10 weeks.  

If you have staff interested in the class, they may contact Laura Sullivan at (304) 347-1374 or email Barbara Good (Barbara@wvsma.com).

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• • Update on 2010 Medicare Fee Schedule
• • Update on Medicare's New Consultations Policy
• • New CMS Enrollment Policy Delayed
• • Medicare Participation Options for Physicians
• • WVSMA Schedules 2010 Business Meeting and Physician Practice Management Conference
• • HEDIS Update
• • UnitedHealthcare News
• • West Virginia Medicaid PDL Update
• • Coding Class Offered