Thursday, February 26, 2015



Read the latest medical news for the San Bernardino County area.

CMS to hold Medicare claims for first two weeks of January

Last week the Centers for Medicare and Medicaid Services (CMS) announced it would hold claims for services paid under the 2015 Medicare physician fee schedule due to technical errors discovered after the new fee schedule was published.

Medicare Administrative Contractors (MACs) will hold claims containing 2015 services for the first 14 calendar days of January 2015 (Thursday January 1 through Wednesday January 14) to allow time for CMS to correct the errors.

The hold should have minimal impact on provider cash flow as, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt.

Claims for services rendered on or before Wednesday December 31, 2014, are unaffected by the 2015 claims hold and will be processed and paid under normal procedures and time frames.


CMA creates new resource summarizing Medicare incentive and penalty programs

Over the past few years, Congress has created a number of programs that call for payment incentives and reductions (referred to as “adjustments” by the Centers for Medicare and Medicaid Services) that impact physicians and their practices. At their inception, most of these programs offered an incentive to participate. However, most of the programs are entering their penalty phases, with complex and potentially conflicting requirements and implementation processes.

To help physicians understand how these programs will affect their practices, the California Medical Association (CMA) has created a new resource, “Medicare Incentive and Penalty Programs: What physicians need to know.” The resource is available free to CMA members in the resource library at


Congress passes a number of health care provisions in the current budget

Congress narrowly passed a $1.1 trillion federal budget that will fund most of the federal government through September 2015. Below is a summary of key health care provisions in the bill.

  • Within the bill, Congress expressed concern that there had not been adequate opportunity for public comment on bundling of surgical codes in the final rule of the Medicare Physician Fee Schedule. The budget bill says that the appropriate methodology has not been tested to ensure that patient care and patient access are not negatively impacted and ponderous administrative burdens placed on providers. It asks the Centers for Medicare and Medicaid Services (CMS) to reconsider that fee schedule provision.
  • The budget includes $5.4 billion of emergency funding to prepare for and respond to the Ebola outbreak.
  • The National Institutes of Health will received $30.3 billion (an increase of $150 million), including $283 million for Ebola-related research.
  • CMS receives no increase in funding over last year ($3.6 billion).
  • The Centers for Disease Control and Prevention (CDC) will receive money to combat prescription drug abuse around the country. Twenty million dollars has been set for prevention of drug abuse and another $12 million has been included under the Substance Abuse and Mental Health Services Administration for the states to expand treatment services for drug addiction. This funding is also expected to support activities to establish or expand prescription drug monitoring databases of physicians writing prescriptions for opiates and pharmacists filling prescriptions.
  • The bill looks at the Medicare Recovery Audit Contractors (RAC) and how audits may be reducing patient access to care. The bill directs CMS to provide education to providers on error reduction. It also asks the agency to develop procedures to reduce backlogs of claims and hearings and asks CMS to provide education to RAC contractors to improve the accuracy of their audits.
  • The bill urges the Office of the National Coordinator for Health Information Technology to decertify electronic health records products that block the sharing of information and to certify only those products that meet current meaningful use program standards.

Lame duck session of Congress adjourns, leaving SGR reform until 2015

In the final hours of the lame duck session, Congress passed a $1.01 trillion spending bill that will keep most of the federal government funded through next September, but it failed to pass a fix for the Medicare sustainable growth rate (SGR). Congress will leave it to be addressed before the April 1 deadline next year, when physicians will be faced with a 21 percent payment cut.

Unfortunately, Congress will begin anew with many new members who have not been a part of the bipartisan, bicameral SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015/S. 2000), which offered a fiscally prudent opportunity for lawmakers to repeal the SGR formula and put Medicare on the path toward a stable, 21st-century program that helps physicians maintain their practices and meets the growing health care needs of the nation’s seniors.

Three committees came to an agreement on reform in 2014, but the new year will bring not only new members, but new committee chairs. However, most of the new committee leadership on both sides of the aisle have said they will likely continue to support the SGR bill.

While Congress’s inability to address this issue once again is frustrating, there continues to be momentum on the SGR. Significant progress is being made on the funding – a point of contention that led to the 17th SGR patch earlier in 2014.

Working to build on the momentum of the Medicare payment policy agreement and the new emerging consensus that the SGR repeal does not need to be offset with other funding, the California Medical Association (CMA) will make Medicare payment reform a major priority again in 2015. However, there will be limited time after the new Congress convenes before the current SGR patch expires on April 1. The House of Representatives is only scheduled to be in session for 37 days before the 21 percent SGR cut takes effect.

CMA leadership will be in Washington, D.C., in February. We will also be asking physicians to meet with their Members of Congress while they are in their home districts in January. And CMA will launch a major physician and patient grassroots campaign. The California Members of Congress need to continue to hear from their physician constituents. We have never been so close to repealing and replacing the SGR, but we must keep the issue on Congress’s front burner. Otherwise, immigration reform, conflicts around the world and budget issues will consume all of their time and attention.

In addition to inaction on SGR, Congress also failed in the lame duck session to extend the Affordable Care Act (ACA) Medicaid (Medi-Cal) primary care rate increase that expires at the end of 2014. We will be pushing Congress to extend this crucial rate increase.

Physicians are hopeful that Congress will build on the progress made this year so that organized medicine can focus on addressing other important health policy issues. Critical health care issues facing Congress next year include the expiring Healthy Families program, graduate medical education, telemedicine and improvements to the ACA.

Contact: Elizabeth McNeil, (800) 786-4262 or

Potential Medicare pay cuts coming in 2015; participation selections due Dec. 31

It's that time of year again – time for physicians to decide about their participation in Medicare. Physicians have until Dec. 31, 2014, to make changes to their status for 2015. In addition to the annual threat of steep payment cuts as a result of the sustainable growth rate (SGR) formula, another factor for physicians to consider is that 2015 will be the first year that the Centers for Medicare & Medicaid Services (CMS) will impose penalties under the value-based modifier (VBM) program for large medical groups of 100 or more physicians.

As always, physicians have three choices regarding Medicare: Be a participating provider; be a nonparticipating provider; or opt out of Medicare entirely.

The VBM penalties and bonuses will not, however, apply to unassigned claims. That means a nonparticipating physician would not be subject to a VBM penalty. According to CMS, more than 1,000 groups of 100 or more eligible professionals will see payment penalties from the VBM in 2015. Next year will also be the base reporting year for the 2017 penalties imposed on smaller practices.

Other penalties that will be applied in 2015 based on 2013 performance—including those tied to quality reporting, meaningful use and e-prescribing—will decrease the limiting charge amounts that nonparticipating physicians can bill to patients for unassigned claims.

The three participations options are as follows:

  • A participating physician must accept Medicare allowed charges as payment in full for all Medicare patients.
  • A nonparticipating provider can make assignment decisions on a case-by-case basis and to bill patients for more than the Medicare allowance for unassigned claims. Nonparticipating physician fees are 95 percent of participating physician fees. If you choose not to accept assignment, you can charge the patient 9.25 percent more than the amounts allowed in the participating physician fee schedule (which equates to 15 percent of the nonparticipating fees).
  • Physicians who opt out of Medicare are bound only by their private contracts with their patients. 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.

Physicians who want to change their participation status for 2015 must send a letter to their Medicare contractor postmarked by December 31, 2014.

The California Medical Association (CMA) also has information on physicians' Medicare participation options in CMA On-Call document #7209, "Medicare Participation (and Nonparticipation) Options." On-Call documents are free to members in CMA's online resource library at Nonmembers can purchase On-Call documents for $2 per page.

Additional information can be found in the American Medical Association (AMA) Medicare Participation Kit. The kit contains a detailed explanation of physician options, a calculator and various sample materials for communicating with patients. The Medicare payment calculator will help you estimate how much your total revenues from Medicare patients would change if you switch your Medicare status from participating to non-participating.

The next SGR Medicare payment cut of ~21 percent is slated to take effect on April 1, 2015, unless Congress passes legislation to stop the cut which they have done 17 times. CMA will be working with AMA to stop the cuts and pass the SGR repeal and Medicare payment reform legislation (HR 4015/S 2000) before April 1.

Contact: Michele Kelly, (213) 226-0338 or



CMS announces new rules to curb Medicare fraud

The Centers for Medicare and Medicaid Services (CMS) announced new rules will improve CMS’ ability to deny or revoke the enrollment of entities and individuals that pose a program integrity risk to Medicare.

According to a press release, the “new safeguards are designed to prevent physicians and other providers with unpaid debt from re-entering Medicare and remove providers with patterns or practices of abusive billing." These changes are expected to save more than $327 million annually.

CMS announced it has already removed nearly 25,000 providers from Medicare. Its strategy for curbing unscrupulous providers includes predictive analytics technology, fingerprint-based criminal background checks and temporarily freezing enrollment of new ambulances and home health providers in seven "fraud hot spots."

"For years, some providers tried to game the system and dodge rules to get Medicare dollars; today, this final rule makes it much harder for bad actors that were removed from the program to come back in," said CMS Deputy Administrator and Director of the Center for Program Integrity, Shantanu Agrawal, M.D.

For more information, see the CMS fact sheet on this rule.

Medicare finalizes fee schedule changes for 2015

The Centers for Medicare and Medicaid Services (CMS) published its 2015 Medicare Physician Fee Schedule final rule Thursday in the Federal Register. The 1,200 word payment rule contains several notable changes.

As earlier proposed, the rule expands the services eligible for telemedicine reimbursement and extends the new payment policies for non-face-to-face care coordination. It allows primary care physicians to be paid for care management of Medicare beneficiaries with two or more chronic conditions. These are tasks (including managing lab and imaging reports, medications and care plans in addition to talking with patients and families on the phone) physicians commonly provide, but have not been paid for in the past.

Although CMS continues to move up the implementation timeline for the Value-Based Payment Modifier (VBM), the final rule scales back the penalties for practices with fewer than 10 physicians as urged by the California Medical Association (CMA) and the American Medical Association (AMA). While the final rule still maintains a potential pay cut of 4 percent for larger medical groups, practices with fewer than 10 physicians will not be subject to more than a 2 percent VBM penalty.  AMA and CMA have called for a slower phase-in of the VBM. CMA is supporting the VBM program reforms in the Medicare sustainable growth rate (SGR) overhaul legislation (HR 4015/S 2000). CMA also continues to fight the inappropriate implementation of the value modifier that discriminates against physicians caring for frail, elderly patients.   

Also removed from the final rule was CMS's earlier proposal to eliminate the CME exemption in the Physician Payments Sunshine Act, which requires reporting and public posting of financial interactions between medical device and drug manufacturers and physicians and teaching hospitals. CMA and AMA joined dozens of other medical associations in calling on the agency to eliminate this requirement because it would “chill physician participation in independent [continuing education] programs.”

CMS is moving forward with the public disclosure of physician quality and meaningful use information on the Physician Compare Website. However, at CMA’s and AMA’s urging,  physicians will be allowed to review the information and correct inaccurate data prior to publication. CMS also pulled back its proposal to publish benchmark information.

CMS is also proceeding with the plan to require physicians to report nine quality measures in three “domains” and one “cross-cutting” measure in 2015 for the Physician Quality Reporting  System (PQRS).

And in 2015, the Physician Quality Reporting System (PQRS) becomes a penalty-only program.  No bonuses will be paid. Physicians must successfully report in 2015 to avoid penalties in 2017.

The final rule includes 350 CPT codes identified as new, revised or potentially misvalued—318 of these changes were based on physician input. These changes represent 86 percent of those recommended by the AMA/Specialty Society Relative Value Scale Update Committee, an expert panel of more than 300 participants that includes physician advisers from every medical specialty. The panel develops and provides relative value recommendations annually to CMS.

Despite strong opposition from AMA, CMA and others in organized medicine, CMS moved forward with the elimination of all 10- and 90-day global surgical packages because CMS says it lacks the ability to verify the number, type and relative costs of postoperative visits. Packages would only include preoperative services and care given the day of surgery. CMS will be transitioning all services with a 10-day global period to a 0-day global period by 2017. All 90-day global periods will be shifted to 0-day global periods by 2018.

CMA continues to urge Congress to pass the bipartisan, bicameral SGR repeal and Medicare physician payment reform legislation (HR 4015/S 2000), which would provide bonuses to physicians for meeting the Medicare PQRS and value modifier standards and overhaul the Medicare payment framework.

For more information about these and other components of the 2015 Medicare Physician Payment Rule, see the AMA summary  or the CMS fact sheets.


Ask the Expert: Do I enter a qualifier in box 14 of the claim form if the patient has Medicare prime and a secondary insurance?

Recently a number of practices have inquired as to whether Medicare requires the three-digit qualifier to be populated in item/box 14 when submitting a claim. Item/box 14, Date of Current Illness, Injury, or Pregnancy (LMP), identifies the first date of onset of illness, the actual date of injury, or the last menstrual period (LMP) for pregnancy, and contains a field allowing one of two qualifiers to be entered.

  • 431: Onset of Current Symptoms or Illness
  • 484: Last Menstrual Period

The Medicare Claims Processing Manual advises that although space is included for a qualifier, Medicare does not use this information. However, many other payors do require the qualifier. So, in instances where Medicare is prime but the patient has a secondary insurance that requires population of the field, practices will need to include the information. Medicare has advised that while it does not require qualifier information, if needed for a secondary payor, Medicare will ignore the qualifier and the claims will be forwarded to the secondary payor through the coordination of benefits contractor for payment.


CMA publishes duals project FAQ

The 2012 California state budget authorized a three-year demonstration project that transitions dual eligibles into managed care and allows them to receive medical, behavioral, long-term supports and services and home-and-community-based services coordinated through a single health plan.

The Cal MediConnect project was approved in 8 counties: Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara. No more than 456,000 individuals will be allowed to enroll into Cal MediConnect. Los Angeles’ enrollment will be capped at 200,000.

To help physicians and their patients better understand the program, the California Medical Association (CMA) has published "Cal MediConnect Physician FAQ: What you need to know about keeping your patients and billing for the dual eligible population." The FAQ is available free to members in CMA's online resource library.

For more details on Cal MediConnect, visit and

Contact: Lishaun Francis, (916) 551-2554 or

CMA leaders meet with Congress on Capitol Hill before election recess

California Medical Association (CMA) physician leaders were in Washington, D.C., for the last week of the Congressional session, reminding California legislators about priority physician issues, such as the repeal of the Medicare sustainable growth rate (SGR) and adoption of long-term Medicare payment reform.

Congress has scheduled a very short lame duck session following the November election during which leadership on both sides hopes to come to an agreement on a spending bill to keep the government running.

Earlier this year, both houses of Congress were very close to a permanent repeal of the badly broken SGR formula. Unfortunately, they were unable to agree on how to fund the repeal, even though the cost to do so was dramatically lower than in previous years.

Unable to come to an agreement on how to fund the repeal, Congress passed a patch to stop the SGR-triggered payment cuts for the 17th time in 10 years. The patch is due to expire on April 1, 2015.

In addition to the SGR, CMA leadership asked that California Members of Congress continue the Medicaid primary care rate increase to Medicare levels after it expires on January 1, 2015, and reauthorize the Healthy Families program, which expires in the fall of 2015.

The CMA physicians also met with Sean Cavanaugh, deputy administrator and director of the Center for Medicare at the Centers for Medicare & Medicaid Services (CMS) about the proposed Medicare 2015 Physician Payment Rule. During the meeting, CMA focused on the implementation of the problematic Value Based Modifier, which directs CMS to reward and penalize physicians based on their efficiency and quality reporting. CMA urged CMS to reduce the penalties and change the program to ensure that it does not prevent physicians from treating the poorest, sickest elderly patients or force physicians out of the program altogether.


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