Number of HMOs as of July 2008
April 29th, 2009
Source: Healthleaders, Inc., Special Data Request, March 2009. (Kaiser Family Foundation)
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April 29th, 2009Doctors face risk of harsh penalties from new Medicare enrollment rules
April 24th, 2009
Washington -- Physician practices are anticipating major difficulties with Medicare enrollment rules that went into effect amid protests from doctors and practice managers. A wrong step by a practice could mean that it loses Medicare revenue or even gets kicked out of the program altogether.
Starting April 1, the time frame under which physicians can bill retroactively for services after successful enrollment or re-enrollment in Medicare has been shortened from 27 months to only 30 days. In addition, doctors must alert contractors of a change in practice location within 30 days, or risk expulsion from Medicare for up to two years.
The policy changes appeared in the final 2009 Medicare physician fee schedule rule and were slated to go into effect Jan. 1. But the American Medical Association and the Medical Group Management Assn. convinced Centers for Medicare & Medicaid Services officials to hold off implementation while they discussed the organizations' concerns.
"Many of the changes to Medicare's enrollment process are cause for concern, and the AMA is working to improve the process so physicians can participate without disruption to their practice," said Board of Trustees Chair Joseph M. Heyman, MD.
Derise Woods, operations project manager for TeamHealth, an emergency department staffing services company based in Knoxville, Tenn., is particularly worried about the shortened retroactive billing period. Far from the flexibility of the old 27-month window, the new 30-day window is counted back from the filing date of an enrollment application that is subsequently approved.
"From a billing standpoint, this will have a great impact on our revenue," Woods said. Time is a precious commodity when it comes to providing medical services, particularly in an emergency department, she added. "You may have situations where providers will go to work before the paperwork can be provided to Medicare."
Fear of punishment
The AMA is still working with CMS to ensure that contractors are clear about the details of the new retroactive billing rule. Some potentially vague language in rule guidance has physicians concerned that not all practices will be allowed even a 30-day retroactive billing period.
Physicians who can't comply with the new retroactive billing timeline are at risk of losing payment for any services they billed before the 30-day limit. But doctors who fail to update their addresses within 30 days of moving face the potentially more costly penalty of being unable to bill the program at all for up to two years.
Leslie Witkin is president of Physicians First Inc., a consulting company based in Orlando, Fla., that provides operational assessments, auditing and other consulting services to doctors. She has heard about Medicare participants who have been afraid to update their billing information with CMS for fear that billing privileges will be revoked.
"Providers out there are trying to keep pace with a lot, and there hasn't been intent or malice on their part, and now you're cutting people off at the knees by taking their revenue," Witkin said.
The AMA is pushing for physicians once again to have up to 90 days to report a change in practice location or ownership.
The harsh penalty of revocation is familiar to Erastus Smith, MD, an internist in Sanford, N.C. He said he was burned by the Medicare program in 2008 when his billing privileges were revoked for 5½ months after it was discovered he mistakenly had been assigned two National Provider Identifiers by CMS.
The development was a huge setback for the solo physician, who estimates that 40% to 60% of his business is based on Medicare pay. As a result of losing his billing privileges, Dr. Smith said his life insurance policy was canceled when he no longer could make payments and his credit rating went down. He also had to give up his receptionist of 26 years because he no longer could afford to pay her.
Dr. Smith is once again billing Medicare, but the experience has made him exceedingly wary. He is renovating a new office space across town that he hopes to move into soon, but he's fearful that any filing error connected to the move could have results similar to last year's disaster.
The new policies "set the stage for some severe problems for physicians," Dr. Smith said. "The vast majority of physicians are bringing a certain comfort to the people we see. These plan changes make it harder for us to do our jobs and get paid."
Looking for good faith
CMS is trying to reassure physicians that it is not trying to punish practices that are acting in good faith.
"Medicare does not intend to revoke those billing privileges," said Jim Bossenmeyer, director for provider and supplier enrollment at the CMS Program Integrity Group. "However, if we were conducting on-site inspections and we determined the supplier was no longer in that practice location, then Medicare may revoke privileges."
Bossenmeyer also said physician offices shouldn't be concerned about the new retroactive billing limit, as long as they update their Medicare enrollment prospectively.
In addition, rather than rejecting incomplete enrollment applications outright, contractors should simply deny the enrollment, he added. Then the physician can send a letter to the contractor within 30 days requesting a corrective action plan, thereby ensuring that the initial filing date -- and the original retroactive billing window -- is preserved.
Nevertheless, the AMA and others are worried that physicians will be punished for delays and glitches that are not their fault. The new provisions come amid reports of continuing serious enrollment problems stemming from last year's transition from older ID numbers to NPIs.
Even before the economic recession, physicians reported that many Medicare contractors already were strained beyond capacity and incapable of handling large enrollment workloads. The ongoing Medicare Administrative Contractor transition also has exacerbated enrollment delays, physicians said.
The print version of this content appeared in the April 27, 2009 issue of American Medical News.
New York budget increases Medicaid fees for physicians
April 24th, 2009
Physicians who treat Medicaid patients in New York state are getting a second significant increase in Medicaid fees later this year thanks to a state budget that invests tens of millions of dollars toward primary and preventive care.
Physician fee-for-service Medicaid pay will reach about 70% of Medicare rates effective Dec. 1. Rates were about 40% of Medicare before the Legislature appropriated $188 million over the last two years to boost physician and nurse practitioner pay, said Liz Dears, senior vice president of governmental affairs at the Medical Society of the State of New York. That first pay raise took effect Jan. 1. Physicians seeing Medicaid patients in federally designated health professional areas also became eligible for an additional 10% fee increase.
The changes are designed to emphasize primary and preventive care over inpatient care and are part of a $132 billion fiscal 2010 budget adopted April 3. The budget, which covers spending beginning April 1, authorizes Medicaid fee-for-service incentives and managed care payments for physicians, hospitals and community clinics that meet medical home standards to be defined this year. It also offers Medicaid care coordination fees to doctors who manage patient care in parts of the state without Medicaid managed care programs.
"These initiatives are critical to ensure that every New Yorker has access to a primary care physician and a patient-centered medical home ... particularly in low-income, underserved and rural areas of the state," said Vito Grasso, executive vice president of the New York State Academy of Family Physicians.
Other health care entities didn't fare as well in the 2010 budget. It includes $2.3 billion in health care-related cuts and new revenues, including tax increases on health plans, reduced Medicaid fees for nursing homes and reduced inpatient fees for hospitals, among other actions.
"Health care providers supported the investments in primary care ... and we understood the economic situation would require some cuts," said Daniel Sisto, president of the Healthcare Assn. of New York State. "However, this budget goes far beyond what was necessary or appropriate, threatening the safety and well-being of millions of New Yorkers who rely on the health care delivery system."
Hospitals will see their inpatient Medicaid fees cut by $225 million, according to the New York State Dept. of Health. Most of this money will be reallocated to hospital clinics, community clinics and doctors. But the budget also provides nearly $270 million for teaching hospitals to care for uninsured patients.
Health plans fared even worse in the budget. It increased taxes on health insurers by $738 million to help fund graduate medical education and other programs, Dears said.
Neither health plans nor their customers can afford these taxes, said Deborah Fasser, spokeswoman for the New York State Conference of Blue Cross and Blue Shield Plans. "Businesses will have to choose between raising an employee's contributions to the company's health plan or eliminating health insurance as a benefit. ... The result will be fewer New Yorkers with health insurance."
Many in managed care
Although the Medicaid fee increases are unprecedented, they won't directly impact many physicians around the state because many Medicaid enrollees are in managed care plans.
Medicaid and Family Health Plus -- a state program that offers health coverage to lower-income families not eligible for Medicaid -- have a combined 4.1 million enrollees. Of those, 2.7 million are in managed care, said New York State Dept. of Health spokeswoman Diane Mathis.
The vast majority of Medicaid patients in New York City are likely enrolled in managed care plans, said Mark Krotowski, MD, president-elect of the New York State Academy of Family Physicians. About 20% of the patients at his solo practice in Brooklyn are in Medicaid managed care.
Drew Merritt, MD, a family physician in semi-rural Marcellus, N.Y., said the first Medicaid fee increase for office visits effective Jan. 1 -- up about $6 to $36 -- isn't really going to impact his practice. He would continue seeing the 5% of his patients who are on Medicaid even if the pay stayed the same.
Despite the mitigating factors, the fee increases are significant because they're the largest in decades, Dears said. "It's not 100% of Medicare, but we're headed in the right direction."
The print version of this content appeared in the April 27, 2009 issue of American Medical News.