Payment Matters

November 29, 2012

CMS Releases its CY 2013 Physician Fee Schedule Final Rule

By: Mark A. Stanley *

CMS has released its Calendar Year (CY) 2013 Final Rule for practitioners who are paid under the Physician Fee Schedule (PFS). CMS anticipates that many non-primary care specialties will see a decrease in payments under the final rule. As a corollary, primary care physicians can anticipate a payment rate increase under the final rule. CMS estimates that family care physicians would experience a 7 percent increase in payment rates, and other primary care physicians will see their payment rates increase 3-5 percent. The final rule may be viewed here [PDF].

CMS anticipates that, without changes to current law, the Sustainable Growth Rate (SGR) adjustment to physician reimbursement will result in an approximate 27 percent cut in payment rates for 2013. This adjustment has historically been reversed through congressional intervention.

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New Medicare and Medicaid Rules Boost Primary Care Reimbursement and Implement Value-Based Payment Methodology

By: John S. Linehan*

On November 1, 2012, CMS released two final rules that included a series of Medicare and Medicaid payment policies and rates for physicians and other health professionals. Among other things, the rules contain payment reforms aimed at strengthening primary care reimbursement as part of CMS’s goal to increase participation by primary care physicians. In addition, the Medicare rule implements an important component of the value-based payment system for physicians to promote higher quality and lower costs in health care delivery. The Medicare and Medicaid rules will take effect on January 1, 2013.

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Court Again Rules Medicare's "Must Bill" Policy for Medicare Dual Eligible Bad Debts Is Reasonable

By: Leslie Demaree Goldsmith

The United States District Court for the District of Columbia once again upheld the decision of the Secretary of Health and Human Services (Secretary) to deny reimbursement for Medicare bad debts associated with copayments and deductibles for Medicare beneficiaries who were also eligible for Medicaid, i.e., dual eligible beneficiaries. Grossmont Hospital Corp., et al., v. Sebelius, Civil Action No. 10-cv-1201 (D.D.C. Nov. 9. 2012). The same court ruled similarly in Cove Associates Joint Venture v. Sebelius, No. 1:10-cv-0316 (D.D.C. Mar. 26, 2012), which we discussed in an earlier Payment Matters article.

In order for a Medicare bad debt to be allowable, a provider must demonstrate, among other things, that no other source, including the State, is responsible for the payment. Pursuant to a Joint Signature Memorandum issued by CMS as a “clarification” of its policy on August 10, 2004, JSM-370, a provider must bill and receive a remittance advice from the State in cases where the State owes nothing or only a portion of a dual eligible patient’s Medicare deductible or copayment.

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