Congress has failed to repeal the Medicare 27.4 percent sustainable growth rate (SGR) cut. The Centers for Medicare & Medicaid Services (CMS) has already instructed Medicare claims administration contractors to hold claims containing 2012 services paid under the Medicare physician fee schedule for the first 10 business days of January (January 1-17, 2012). Physicians should be aware of the possibility of extended delays due to workflow issues and may want to establish some contingencies for delayed payment.
The California Medical Association (CMA) suggests that participating and non-participating physicians bill their usual and customary fees-for-services to Medicare. Billing at your customary fee ensures that national data reflects actual charges rather than payment rates, and ensures that Medicare pays you at the highest amount possible when the claim is processed. Do not bill at a lower amount; you may not have the benefit of automatic reprocessing of your claims if the amount allowed is more than you charged. If you bill at a lower amount, you would need to request your claims be reopened and the charged amount corrected.. For non-participating physicians, the patient fee is calculated as the difference between the Medicare limiting charge, or your submitted charge, whichever is lower.
Practices have the option to hold claims until Congress determines what the payment amounts will be, or continue to submit claims using your normal submission process. Medicare contractors will price the claims in the system based on the fee schedule provided by CMS for January 17, 2012. Congress could take action after that date, which may result in reprocessing of your claims to collect the additional amount that may be due. If you hold claims, you may avoid any issues with your patients in trying to collect additional amounts based on a revised fee schedule. However, with the current track record of Congress, a decision on when they may revise the fee schedule is uncertain. Whatever action you choose to take may have a significant impact on your cash flow from Medicare.
Physicians who rely heavily on Medicare reimbursement should be aware that, as in past years, it may take up to 25 days for payment for 2012 services to be made on the held claims. Begin now to establish any financial contingency plan you may need.
CMA is strongly urging Congress to return to Washington, D.C., on January 3 to stop the Medicare SGR fee-for-service payment cut IMMEDIATELY. We are urging Congress to delink the Medicare SGR stop-gap from the other controversial issues so that Congress can get this done as soon as possible. CMA has also asked CMS to provide advance payments to physician practices experiencing extreme financial hardship as well as advances for those physicians who must purchase outpatient drugs for their patients.
CMA will continue to advocate on your behalf and keep you informed.
Contact: CMA reimbursement helpline, (888) 401-5911 or mkelly@cmanet.org.