Monday, January 13th, 2014
If you are an eligible professional (EP), the last day you can register and attest to demonstrating meaningful use for the 2013 Medicare EHR Incentive Program isFebruary 28, 2014. You must successfully attest by 11:59 p.m. Eastern Standard Time on February 28 to receive an incentive payment for your 2013 participation.
You must attest to demonstrating meaningful use every year to receive an incentive and avoid a payment adjustment.
Medicaid Eligible Professionals
EPs participating in the Medicaid EHR Incentive Program need to refer to their state deadlines for attestation information.
Payment adjustments for EPs will be applied beginning January 1, 2015, to Medicare participants that have not successfully demonstrated meaningful use. The adjustment is determined by your reporting period in a prior year. For more information, visit the payment adjustment tipsheet for EPs.
If you are only eligible to participate in the Medicaid EHR Incentive Program, you are not subject to these payment adjustments.
Review all of the important dates for the EHR Incentive Programs on the HIT Timeline.
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Friday, January 10th, 2014
Beginning on April 1, 2014, all paper claims filed to NGS Medicare must be submitted using the revised form CMS 1500 Version 02/12. All paper claim submissions using the older format will be returned to providers as unprocessable after April 1, 2014.
To prepare for the change in claim form, NGS implemented a new Optical Character Recognition System (OCR) in November 2013. We have been experiencing delays with needed updates to this OCR system. Unfortunately, this has caused a short term need to manually verify all paper claims data. This has increased the overall inventory of paper claims pending validation.
Until these paper claims are completely entered, we cannot currently respond fully to claim status related questions. In all likelihood, the claims have been received and are awaiting claim detail entry into MCS. An extensive effort is underway to expedite processing for these outstanding paper claims.
This issue applies only to the small volume of paper claims received. The vast majority of electronically submitted claims and the claims submitted using the free features on the Connex portal are being processed, meeting all timeliness requirements. Please checkwww.ngsmedicare.com/Connex for details.
We regret the delay in handling the paper claims submitted.
James D. Bavoso
Provider Outreach & Education
National Government Services
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Thursday, January 9th, 2014
Bloomberg News (1/9, Lopatto) reports that the CDC connected this rise in STD infection rates to “inadequate testing among people stymied by homophobia and limited access to health care.” According to CDC STD Prevention Division Director Gail Bolan, “We know that having access to high-quality health care is important to controlling and reducing STDs. Some of our more-vulnerable populations don’t have access. There are a number of men who come in to our clinic for confidential services because they’re too embarrassed to see their primary care doctors.”
The Huffington Post (1/9) quotes the report as recommending “dual therapy with ceftriaxone and either azithromycin or doxycycline” for gonorrhea treatment.
According to Medscape (1/9, Lowes), the report attributes the rise in syphilis entirely to men, particularly MSM.
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Thursday, January 2nd, 2014
NEW YORK POST
WASHINGTON — A group of New York doctors is suing insurance giant UnitedHealthcare, charging that it booted doctors from its network to avoid cost hikes imposed by ObamaCare.
The company’s decision to kick more than 2,000 docs from its Medicare Advantage network threatens to harm elderly and disabled patients, according to the filing in Brooklyn federal court.
“By terminating numerous physicians from the . . . network, United seeks to stem financial losses occasioned by reduced federal payments under the Affordable Care Act,” the suit launched by the Medical Society of the State of New York claims.
“This, of course, comes at the expense of physicians,” the suit continues, arguing that the company violated doctors’ contracts by failing to give sufficient notice, among other things.
Tugging at the heartstrings, the suit specifically mentions elderly and disabled patients “who must now either find new physicians (including traveling farther distances to find a participating . . . provider), switch plans to continue treatment with the terminated physicians, or pay significant additional out-of-pocket costs to continue treatment with an ‘out-of-network’ provider.” It accuses United of “shifting the financial burdens imposed by the Affordable Care Act from itself, a multibillion-dollar company,” to providers and patients.
Medical Society President Sam Unterricht told The Post the company’s decision was unfair to patients, since they had to choose a new plan under Medicare Advantage, a private alternative to traditional Medicare, by Dec. 7, when company Web sites still showed doctors who were being kicked out of the network at the start of the new year.
“For some people who are medically fragile it can really be dangerous. There can be gaps in care,” he said.
Unterricht said reduced Medicare Advantage payments to physicians are being used as a cost-saving measure to fund ObamaCare. He said docs would get paid 20 percent or even 40 percent less per patient. “A lot of doctors are not going to be able to accept that and really give good medical care at that kind of a price,” he said.
UnitedHealthcare defended its decision to reduce its roster of doctors. “The changes we are making to our network will encourage higher quality and more affordable Medicare coverage,” UnitedHealthcare said in a statement. “We will remain focused on serving our members and will continue to provide them a broad and comprehensive choice of doctors in New York.”
The Medicare Advantage savings used to help fund ObamaCare shaved nearly $200 billion over a decade under the law. Democrats have long complained that the program amounts to an overpriced subsidy to private companies and a burden to taxpayers.
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Thursday, January 2nd, 2014
–New Law Includes Physician Update Fix through March 2014–
On December 26, 2013, President Obama signed into law the Pathway for SGR Reform Act of 2013. This new law prevents a scheduled payment reduction for physicians and other practitioners who treat Medicare patients from taking effect on January 1, 2014. The new law provides for a 0.5 percent update for such services through . President Obama remains committed to a permanent solution to eliminating the Sustainable Growth Rate (SGR) reductions that result from the existing statutory methodology. The Administration will continue to work with Congress to achieve this goal.
The new law extends several provisions of the Middle Class Tax Relief and Job Creation Act of 2012 (Job Creation Act) as well as provisions of theAffordable Care Act. Specifically, the following Medicare fee-for-service policies have been extended. We also have included Medicare billing and claims processing information associated with the new legislation. Please note that these provisions do not reflect all of the Medicare provisions in the new law, and more information about other provisions will be forthcoming.
Section 1101 – Medicare Physician Payment Update – As indicated above, the new law provides for a 0.5 percent update for claims with dates of service on or after January 1, 2014, through . CMS is currently revising the 2014 Medicare Physician Fee Schedule (MPFS) to reflect the new law’s requirements as well as technical corrections identified since publication of the final rule in November. For your information, the 2014 conversion factor is $35.8228.
Section 1102 – Extension of Medicare Physician Work Geographic Adjustment Floor – The existing 1.0 floor on the physician work geographic practice cost index is extended through . As with the physician payment update, this extension will be reflected in the revised 2014 MPFS.
Section 1103 – Extension Related to Payments for Medicare Outpatient Therapy Services – Section 1103 extends the exceptions process for outpatient therapy caps through Medicare Claims Processing Manual, Pub.100-04, Chapter 5, Section 10.3.. Providers of outpatient therapy services are required to submit the KX modifier on their therapy claims, when an exception to the cap is requested for medically necessary services furnished through . In addition, the new law extends the application of the cap and threshold to therapy services furnished in a hospital outpatient department (OPD). Additional information about the exception process for therapy services may be found in the
The therapy caps are determined for a beneficiary on a calendar year basis, so all beneficiaries began a new cap for outpatient therapy services received on January 1, 2014. For physical therapy and speech language pathology services combined, the 2014 limit for a beneficiary on incurred expenses is $1,920. There is a separate cap for occupational therapy services which is $1,920 for 2014. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached, and also apply for services above the cap where the KX modifier is used.
Section 1103 also extends the mandate that Medicare perform manual medical review of therapy services furnished January 1, 2014 through March 31, 2014, for which an exception was requested when the beneficiary has reached a dollar aggregate threshold amount of $3,700 for therapy services, including OPD therapy services, for a year. There are two separate $3,700 aggregate annual thresholds: (1) physical therapy and speech-language pathology services, and (2) occupational therapy services.
Section 1104 – Extension of Ambulance Add-On Payments – Section 1104 extends the following two Job Creation Act ambulance payment provisions: (1) the 3 percent increase in the ambulance fee schedule amounts for covered ground ambulance transports that originate in rural areas and the 2 percent increase for covered ground ambulance transports that originate in urban areas is extended through ; and (2) the provision relating to payment for ground ambulance services that increases the base rate for transports originating in an area that is within the lowest 25th percentile of all rural areas arrayed by population density (known as the “super rural” bonus) is extended through . The provision relating to air ambulance services that continued to treat as rural any area that was designated as rural on December 31, 2006, for purposes of payment under the ambulance fee schedule, expired on June 30, 2013.
Section 1105 – Extension of Medicare Inpatient Hospital Payment Adjustment for Low-Volume Hospitals – The Affordable Care Act allowed qualifying low-volume hospitals to receive add-on payments based on the number of Medicare discharges from the hospital. To qualify, the hospital must have less than 1,600 Medicare discharges and be 15 miles or greater from the nearest like hospital. This provision extends the payment adjustment through , retroactive to October 1, 2013. Be on the alert for further information about implementation of this provision.
Section 1106 – Extension of the Medicare-Dependent Hospital (MDH) Program – The MDH program provides enhanced payment to support small rural hospitals for which Medicare patients make up a significant percentage of inpatient days or discharges. This provision extends the MDH program until , and is retroactive to October 1, 2013. Be on the alert for further information about implementation of this provision.
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Thursday, December 19th, 2013
December 19, 2013
Yesterday the US Senate passed by a 64-36 margin a two-year Budget deal that includes a 3-month delay of the 24% Medicare SGR physician payment cut scheduled to go into effect January 1. Last week, the House of Representatives passed the measure and it is expected to be signed into law by the President. The 3-month “bridge” also includes a 0.5% update.
It should also be noted that while the proposal mitigated some of the cuts to federal programs imposed as a result of the sequestration, it left in place the vast majority of the $1 trillion in sequestration cuts to many federal programs including the 2% cut in Medicare payments imposed earlier this year.
As has been frequently reported, serious discussions regarding a proposal to enact a full repeal of the SGR formula are occurring on a parallel track and will continue in early 2014.
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Wednesday, December 18th, 2013
The Medical Society of the State of New York (MSSNY) has filed an amicus brief with the Second Circuit Court of Appeals in connection with United Healthcare’s terminations of physicians in their Medicare Advantage network. An additional amici brief was filed with the Second Circuit Court of Appeals regarding UHC’s appeal of the District Court ruling on Tuesday, December 10.
Along with Fairfield and Hartford Counties, several additional Connecticut counties and specialty societies have now joined as part of the amici brief. Other state and national organizations have also joined as part of the amici brief:
United Healthcare has filed a motion for emergency expedited briefing and argument in its appeal to the United States Court of Appeals, Second Circuit, seeking to overturn the preliminary injunction granted by a lower federal court in favor of plaintiffs Fairfield County Medical Association and Hartford County Medical Association, which enjoins United from removing certain physicians from its Medicare Advantage network effective, February 1, 2014.
In New York State, physicians are being terminated on December 31, 2013. Again, in New York, if patients don’t like their Managed Care plan starting in January, they have until February 14, 2014, to revert back to original fee-for-service Medicare, not another Medicare Advantage plan. United argues that its participation agreement with physicians clearly allows United to amend the agreement to add or remove product lines which a physician may participate, including the Medicare Advantage product. According to United, the preliminary injunction deprives United of its contractual right to determine the size and composition of its Medicare Advantage network. United also argues the lower court incorrectly held that the county medical societies have legal standing to bring the legal action on behalf of its members. The participation agreement between United and its physicians includes a provision that requires all disputes to be subject to binding arbitration, and, United argues, the lower court’s ruling is that that the medical societies have standing to bring a lawsuit since United’s actions run “roughshod” over the contract terms its participating physicians.
MSSNY needs to hear from regarding physicians in New York who have been similarly terminated from United’s Medicare Advantage Network “without cause.”
Please contact Regina McNally, VP Socio-Medical Economics at email@example.com MSSNY needs terminated physicians to provide us with the written notice of termination from the Medicare Advantage Network; the United participation agreement; and we need you to tell us how the anticipated hardship caused by the termination will harm your medical practice and your Medicare Advantage patients.
Help us to help you.
Attorney General Schneiderman, at MSSNY’s urging, has written CMS, asking that the open enrollment period be extended for patients to switch between Medicare Advantage Plans. CMS has not yet responded.
As always, keep MSSNY informed of your Medicare Advantage terminations and of any problems you and your patients are having.
Sam L. Unterricht, MD
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Monday, November 25th, 2013
There is a litany of national news service articles this week, covering the full political spectrum, highlighted concerns expressed by physicians in New York State regarding unfair treatment by health insurance companies offering coverage in New York’s Health Insurance Exchange.
Articles appeared in:
· US News & World Report and
· Kaiser Health News highlighting the challenges patients may face in New York’s Health Insurance
Exchange as a result of a number of concerns identified through the preliminary results ofMSSNY
survey gauging physician experiences with health insurance companies offering coverage through
New York’s Health Insurance Exchange.
The problems with health insurers identified in the MSSNY survey include failure to communicate whether a physician is part of an Exchange plan, failure to provide information regarding reimbursement for providing needed patient care and, in many cases, offering fees that, generally speaking, are significantly below existing commercial coverage. MSSNY continues to regularly communicate with top staff at the New York Exchange to convey these concerns. Last week’s MSSNY’s Advocacy Matters program featured top staff of the New York Health Insurance Exchange describing the roll-out of the Exchange in New York, including responding to many physicians’ questions. To watch a recording of this webinar, click here.
We also continue to urge physicians to complete the survey so that it is more representative of physician experiences statewide. If you have not already done so, we urge you to please complete the survey here.
We Need to Hear from You
MSSNY has contacted the NYS Department of Health regarding complaints of some physicians that they are listed as a participating physician in a health plan exchange network, but were not provided any written notice by the health plan that gave prior notification of such participation requirement, or the terms and conditions of such participation, including but not limited to, the fee schedule applicable to the exchange product. The NYS Department of Health has asked MSSNY to provide specific examples of physicians who believe that the health plan failed to provide prior written notice of participation in the exchange product. If a physician is interested in having the DOH investigate the specifics, the doctor should send an email to Regina McNally, VP of Socio-Medical Economics at firstname.lastname@example.org The email should identify the plan name and identify whether or not they have any contract with the specific insurer.
Sam L. Unterricht, MD
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Thursday, November 14th, 2013
CONTRACTS IN THE NEW HEALTH CARE WORLD
Question: I received an amendment to my payor participation agreement related to increased payments under the Affordable Care Act. Any reason not to sign?
Answer: Maybe. We have seen some amendments to participation agreements of late that have been presented to medical practices to implement enhanced primary care payments under the Affordable Care Act. While the payments may be easy to accept, be careful of the trade-off. Be especially concerned if the amendment includes language that provides the payor with new rights to audit your practice or new grounds for termination, and consult experienced health care counsel before signing.
The days of signing so-called “standard” managed care agreements and amendments should be behind you. This holds true for other agreements, as well, e.g., data sharing agreements, EHR agreements, business associate agreements, employment agreements, leases, etc. Today, most physicians have complex relationships with multiple parties, each governed by a written agreement that may implicate any number of statutes or regulations and which may limit your ability to freely contract with other parties. Bottom line: it is more important than ever to read and understand the fine print.
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Thursday, November 14th, 2013
AMA submits recommendations to Senate Finance and House Ways & Means Committees on repealing the SGR
On Oct. 30, the Senate Finance Committee and the House Ways and Means Committee released a bipartisan, bicameral discussion draft proposal that “would permanently repeal the SGR update mechanism, reform the fee-for-service (FFS) payment system through greater focus on value over volume, and encourage participation in alternative payment models.” The AMA submitted recommendations to the committees on Nov.11, to build upon and strengthen the draft proposal to best achieve the shared goal of developing a new, more stable Medicare payment and delivery system that supports high-quality care. The AMA will continue its advocacy efforts with the committees and all members of Congress to shape and advance legislation this year to eliminate the SGR.
AMA, state and specialty societies urge CMS to intervene in Medicare Advantage terminations
The AMA and 81 state and specialty societies sent a letter on Nov. 8, urging CMS to take immediate action to ensure that beneficiaries participating in Medicare Advantage (MA) plans have accurate and reliable information to make health insurance elections during the 2014 Open Enrollment period, and to address a lack of MA sponsor transparency on network adequacy. The AMA, state medical associations, and national medical specialty societies have been contacted by hundreds of physicians who have been terminated from 2014 MA plan networks in certain markets. The terminations are “without cause” and have been timed in a manner that undermines the accuracy and reliability of the information Medicare beneficiaries rely upon to make important decisions about their 2014 health insurance coverage. The timing and process used to communicate the terminations and modifications to the networks are inconsistent with CMS guidance and regulations. The AMA, state and specialty societies urged CMS to act to ensure that the program is transparent and equitable.
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