SDCMS "News You Can Use"
— March 3, 2010
Executive Director Comments:
- Late on Tuesday, March 2, 2010, the Senate voted 78–12 to pass HR 4691 [1] ("The Temporary Extension Act of 2010"), which included provisions to extend 2009 Medicare physician payment rates through the end of March 2010 — stopping for only one month the implementation of the 21% cuts.
- I am not going to get excited by this temporary fix as it neither resolves the underlying problem, nor addresses the lack of increases as practice costs continue to rise (discussions continue in the House and Senate on next steps, including implementing still another short-term patch to the sustainable growth rate (SGR) formula).
- SDCMS and CMA are committed to eliminating the SGR permanently and moving to an inflation-indexed measure that addresses the constantly increasing costs to practice medicine.
- We are committed, as well, to including a GPCI (geographic practice cost index) fix so that San Diego County and other urban areas are no longer paid at California's lowest rates.
- If you have real-world stories to share with us that tell how this lack of a permanent fix to Medicare is hurting your patients, let me know at Gehring@SDCMS.org [2].
CMA ACTIONS: CMA sent a delegation this week to Washington, DC, to lobby for an SGR solution.
SDCMS ACTIONS: Your SDCMS leadership team, as well, will be in Washington, DC, in 12 days to lobby for SGR and GPCI corrections to be included in any reform or, in the event overall reform efforts collapse in Congress, to still be addressed. If you have real-world stories that we can tell in DC as to how this lack of a fix to Medicare is hurting your patients, please let me know at Gehring@SDCMS.org [2]!
CMS ORDERS MEDICARE CONTRACTORS TO HOLD CLAIMS FOR 10 DAYS
CMS has told its contractors to hold claims for 10 days. Participating physicians should continue to submit Medicare claims at their usual and customary rates. Nonparticipating physicians may want to consider holding their charges for a few weeks until it is clear what Congress plans to do about the cuts. For more information, see the “Frequently Asked Questions” below.
PHYSICIAN PARTICIPATION DEADLINE: MARCH 17, 2010
Physicians are now facing a deadline of March 17, 2010, to determine their Medicare participation status for 2010. Participation decisions are binding for one year, unless physicians choose to opt out entirely. Opting out of Medicare is a serious decision that must be made with careful consideration. A decision to opt out is effective for two years (unless the physician withdraws the decision within the 90-day grace period). For more information on withdrawing a decision to opt out, see the “Frequently Asked Questions” below.
PHYSICIAN PARTICIPATION OPTIONS
Physicians, as always, have three choices regarding Medicare: be a participating provider; be a nonparticipating provider; or opt out of Medicare entirely.
- A participating physician must accept Medicare allowed charges as payment in full for covered services for all Medicare patients.
- A nonparticipating provider can choose to accept or not accept assignment on Medicare claims on a claim-by-claim basis. This means that on a claim-by-claim basis, they can choose to get reimbursed at the Medicare allowed rate or at a nonparticipating rate. Nonparticipating physician fees are 95% of participating physician fees. If you choose not to accept assignment, you can charge the patient 9.25% more than the amounts allowed in the participating physician fee schedule (this is known as the “limiting charge”).
- Physicians who opt out of Medicare are bound only by their private contracts with their patients. Physicians who opt out can only treat Medicare beneficiaries if the patients agree to a private contract. Therefore, by opting out you run the risk of losing Medicare patients because they may not want to privately contract with you at higher out-of-pocket costs than what is allowed under Medicare. Medicare’s limiting charges do not apply to these contracts, but Medicare does specify that these contracts contain certain terms. When a physician enters into a private contract with a Medicare beneficiary, both the physician and patient agree not to bill Medicare for services provided under the contract.
FREQUENTLY ASKED QUESTIONS
Below are answers to the most frequently asked questions regarding Medicare participation. For more information on your Medicare participation options, see CMA ON-CALL document #0151 [3], "Medicare Participation (and Nonparticipation) Options." SDCMS-CMA members can click [4] here to access this document.
Question: How do I notify the Medicare contractor if I want to become nonparticipating?
Answer: In order for you to become a nonparticipating provider, you must submit a letter to Medicare, preferably on your letterhead, indicating that you wish to become a nonparticipating physician. The letter should include your provider number (PTAN), your NPI, and your name, and the letter must be signed by the physician or authorized representative. The effective date for any election made during this enrollment period is January 1, 2010. For a group, the decision to become nonparticipating applies to all members of the group.
Question: If I change to nonparticipating, what is the effective date? How will this impact claims I have submitted?
Answer: The participation enrollment period is an annual process, and is always effective January 1 for physicians currently enrolled in Medicare. If you decide to change to a nonparticipating status, and you have collected more than the beneficiary responsibility charges for any patient since January 1, you must refund any excess to the patient.
Question: How much do I submit as my billed charge?
Answer: As a participating physician, we encourage you to bill your usual and customary rates. If a change is made retroactively that results in an increase to the fee schedule, Medicare will only adjust payments up to the lower of the submitted charge or the fee schedule. Nonparticipating physicians may not submit charges that are more than the limiting charge. If your submitted charge exceeds the limiting charge, you and your patient will receive notification on your EOB, and must refund any excess amounts paid by the patient. Nonparticipating physicians may want to consider holding their charges for a few weeks until it is clear what Congress plans to do about the cuts.
Question: Is opting out a viable option?
Answer: Medicare laws allow physicians to opt out of Medicare Part B and privately contract with Medicare beneficiaries, subject to certain restrictions and rules. Less than half of one percent of physicians treating Medicare patients have chosen to opt out (and nearly half of these opt out physicians are psychiatrists). Opting out is rare and raises numerous complicated issues for your practice and patients. It should not be done without careful consideration and, if possible, consultation with an attorney. More information is available in CMA ON-CALL document #0151 [5], "Medicare Participation (and Nonparticipation) Options." Physicians considering opting out are strongly encouraged to review this document. SDCMS-CMA members can can click [4] to access this document.
Question: If I choose to opt out of Medicare, can I change my mind if Congress acts to repeal the SGR or freeze the cuts for this year?
Answer: You have 90 days from the effective date of your opt out affidavit to withdraw the affidavit and effectively reverse your opt out election. (You also must take additional steps, including refunding any amounts collected from patients above the Medicare limiting charges.) If not withdrawn, your decision to opt out of Medicare remains effective for two years. During this time, and after the 90-day grace period has elapsed, you may treat Medicare beneficiaries only through private contracts consistent with the requirements of opting out. Failure to abide by the opt-out provisions will invalidate the affidavit and your private contracts with your patients, which may result in serious consequences. For more information, refer to CMA ON-CALL document #0151 [5], "Medicare Participation (and Nonparticipation) Options." SDCMS-CMA members can can click [4] to access this document.
Question: If I choose to opt out of Medicare, will this affect my other contracts or payments from supplemental plans?
Answer: If you opt out of Medicare, you will also be opted out for any Medicare Advantage plan. Medicare Medi-gap plans will not reimburse your services. Your patients may also have problems collecting on any other supplemental plan, depending on the nature of the plan.
IF YOU WISH TO CONTACT YOUR SENATORS AND REPRESENTATIVE, HERE IS THE CONTACT INFORMATION
You may call (800) 833-6354 (AMA's Grassroots Action Center) and be in touch with the senators' offices in under 30 seconds, or you may call, fax, or email (via their websites) with the information below:
Sen. Dianne Feinstein
Click Here for Website/Email [6]
T: (202) 224-3841
F: (202) 228-3954
Sen. Barbara Boxer
Click Here for Website/Email [7]
T: (202) 224-3553
F: (202) 224-0454
To find your U.S. House representative, click here [8]. You may call (800) 833-6354 (AMA's Grassroots Action Center) and be in touch with your congressional representative's office in under 30 seconds, or you may call, fax, or email (via their website) with the information below:
Rep. Darrell Issa
Click Here for Website/Email [9]
T: (202) 225-3906
F: (202) 225-3303
Rep. Brian Bilbray
Click Here for Website/Email [10]
T: (202) 225-0508
F: (202) 225-2558
Rep. Bob Filner
Click Here for Website/Email [11]
T: (202) 225-8045
F: (202) 225-9073
Rep. Duncan Hunter
Click Here for Website/Email [12]
T: (202) 225-5672
F: (202) 225-0235
Rep. Susan Davis
Click Here for Website/Email [13]
T: (202) 225-2040
F: (202) 225-2948