Posts Tagged ‘“doc fix”’

SGR Update — Fix Remains High Priority for 113th Congress

In Uncategorized on August 27, 2013 at 6:28 pm

Congressional leaders remain committed to finding a permanent solution to the SGR problem that has plagued the Medicare program and provider payments for over a decade.  Although there has long been bi-partisan agreement that the SGR formula developed during the Clinton Administration was seriously flawed, a permanent fix has remained elusive. 

Although an SGR fix is not imminent, due to a convergence of factors, a permanent fix appears achievable in 2013.  All of the Congressional Committees (Senate Finance, House Ways and Means and House Energy and Commerce) that share jurisdiction over Medicare Physician Payment reforms have held hearings and solicited feedback from stakeholders on possible permanent solutions.  Democratic and Republican leaders in both the House and Senate remain committed to finding a permanent solution whereas in years past, the level of commitment to finding a permanent fix has not been as strong. 

Draft proposals have been circulated amongst the various physician and other healthcare organizations, and industry feedback and reaction have been sought. 

If Congress should fail to come up with a permanent fix before the end of 2013, current estimates are that a cut of approximately 24% in provider payments will be necessary to comply with the SGR law. 

Some of the common themes that are emerging as part of the SGR discussions center around the following concepts:

Repeal SGR and replace with statutory increases (possibly 1 – 2 % per year but still to be determined) for a period of time (possibly 3 – 5 years but still to be determined). This would eliminate the 24 % cut slated for January 1, 2014.

  1. Incorporate Specialty Specific Quality Measures as part of the payment formula (aka Update Incentive Program).
  2. Provider payments would be a combination of a “base rate” plus a variable rate tied to quality/performance (Specialty Specific Quality Measures).
  3. Score on Quality would be based upon a comparison against peers (risk adjusted) AND compared to the individual provider’s prior year scores AND provider participation in specialty specific clinical improvement initiatives.
  4. Each provider would “self-identify” with a peer cohort (i.e. providers of the same specialty); and provide information on each of the following:

*             Identifies the peer group the provider wants to be compared to; and
*             Provides information on each quality measure applicable to such peer group to which the provider shall be assessed.

The Secretary of HHS will be responsible for developing the methodology for assessing the performance of providers with respect to the measures and with developing the methods for collecting information needed for such assessments.  The Secretary is directed to establish these processes in a way that minimizes the “… amount of administrative burden needed to ensure reliable results.”

In reviewing the proposals, several administrative/operational questions have arisen.  These include: 

  • Auditing/data retention requirements
  • Claims reporting requirements
  • Administrative complexity of process
  • How/when will payments be made
  • What will be necessary to support provider participation in this type of payment model
  • Predictability of payment


Clearly, much still needs to be done to address and hopefully to resolve this ever-pressing matter.

reprinted with permission, Healthcare Business & Management Association (HBMA)


The Fix Is In… for 2012

In Uncategorized on February 29, 2012 at 5:12 pm

The House and Senate have both voted to approve, and the President has signed into law, legislation preventing the scheduled 27.4% SGR related cut from taking effect on March 1.   While many issues are in fact addressed in this legislation – ranging from outpatient therapy caps to ambulance add-on payments; from the governments provision of bad debt payments to insitutions to the payment of the technical component of certain pathology services, etc…, by far the most anticipated and relevant item impacted by the legislation is the Medicare Physician Fee Schedule rates:

Physician Payment Rates – This provision prevents a 27.4 percent cut in Medicare physician payment rates slated to begin on March 1, 2012, and instead freezes payment rates at their current level though December 31, 2012.  This provision also requires the Government Accountability Office (GAO) and HHS to submit reports to assist Congress in the development of a long-term replacement to the current Medicare physician payment system.

Physicians can breathe a sigh of relief, as physician payments are safe for the remainder of 2012…  but a permanent fix is an ever increasing necessity, for now, physician practices will face a mounting 35% payment threat from Medicare in 2013, absent additional furture Congressional intervention.

2012 Medicare Physician Fee Schedule Is In the Crosshairs Again… AKA, “The Perils of The SGR”

In Uncategorized on February 8, 2012 at 3:21 pm

Although most of us were not around during the era of silent movies, many of you may be familiar with a genre of movie referred to as a serial motion picture….  One of the more famous of this genre was titled, “The Perils of Pauline.”   In this series, the heroine, Pauline, would be put into a perilous situation (i.e. tied to the railroad tracks with a fast approaching train, tied to a barrel filled with explosives, etc.) and during the course of the installment, Pauline would miraculously escape near certain death at the last possible moment.  Each installment would end with words to the effect, “Tune in Next Week.”

Anyone familiar with “The Perils of Pauline” series cannot help but recognize the parallels between Pauline and healthcare providers as we watch our government deal with theSGR problem.  Every few months, it seems, Congress waits until the last possible moment to fix the SGR cut and avoid the financial calamity that would ensue if Congress allowed the cut to take effect. 

As we all know, in the latest “Perils of SGR,” Congress voted to delay any resolution of the SGR – and the potential 27% reduction in the Medicare Physician Fee Schedule — in late 2011.  However, that “fix” was only for two months and we were all told to, “Tune in next month,” as our intrepid Congress attempts to once again step in at the last minute to avoid yet another possible cut in physician fee schedule payments on March 1, 2012.  Unfortunately, whereas “The Perils of Pauline” was a movie, the perils of the SGR cut are all too real.

On January 24th a House-Senate Conference Committee met for the first time to begin formal work on resolving the SGR differences between the House and Senate.  Although this was the first meeting by the Representatives and Senators, their staffs had been meeting regularly leading up to this meeting.  The Conference Committee met again on February 1st and 2nd, and additional meetings are anticipated over the next few weeks, during which committee members are to present all ideas and solutions. 

Representative Renee Ellmers (R-NC), a freshman Member of Congress on the Conference Committee (and a healthcare executive prior to being elected to Congress in 2010) suggested a two-year extension for the SGR fix, thus giving the Congress time to find alternate solutions.  Follow-up remarks made by several members of the Conference Committee indicated that there was at least some bi-partisan interest in coming up with a permanent fix to the SGR rather than another in the long series of temporary fixes. 

The stumbling block for enacting a permanent SGR solution has not been the lack of an alternative formula, but rather how to pay for any fix the Congress might adopt.  Current estimates are that adopting a permanent fix would increase the federal deficit by approximately $300 billion over the next year unless corresponding spending reductions were made to offset the debt. 

The AMA and some other organizations have suggested that money saved by the ending of the war in Iraq could be used to pay for the SGRfix.  The current federal budget (which projects spending out for 10 years) assumed that theIraq war would go on for several more years and money was budgeted for that purpose.  However, with the ending of the war, the money previously budgeted will no longer be needed.  Therefore, from a budgeting standpoint, this money could technically be redirected to pay for the SGR fix, rather than being set aside for the war inIraq.  Doing so would not increase the projected federal deficit beyond current estimates as this would be viewed as a reprogramming of dollars already budgeted for another purpose.  It remains to be seen whether the Congress will pursue this budgetary line of reasoning or not. 

Although it appears unlikely that Congress would allow the 27% SGR-related cut to go into effect on March 1, there are no guarantees.  Stay tuned for the next installment…   

Adapted and reprinted with permission of Bill Finefrock, Washington Report – January 2012.

Senate Finally Passes 6-month SGR “Fix” – Sent To House For Vote

In Uncategorized on June 18, 2010 at 9:06 pm

The Senate, via unanimous consent, has passed a 6 month SGR “fix”.  The legislation was broken out from the larger tax extenders/unemployment legislation to which it had been attached.  Here is a summary of the proposal passed by the Senate:

Medicare Physician Payment: Provides a 2.2% increase in reimbursement levels for June-November of 2010. Spends $6.4 billion over five and ten years.

Hospital Payments: Prohibits Medicare from reopening or adjusting claims made by hospitals during the three days preceding a patient’s inpatient admission.

Pension Relief: Offers the same relief from pension funding obligations for companies that will result in fewer tax-preferred contributions to pension plans and therefore more taxable income for the firms, and generates $675 million in outlay savings due to lower than expected payments by the Pension Benefit Guarantee Corporation (PBGC).  Saves $2.8 billion over ten years.

IRS Data Match: Includes provisions allowing the IRS and CMS to coordinate data matching efforts with regard to delinquent tax debts owed by Medicare providers, and to take such information into account when releasing reimbursement payments and accepting new providers.  Saves $175 million over five years and $425 million over ten.

The legislation has been sent to the House for consideration but the House has adjourned for the day.  The soonest the House will be able to take up this proposal – assuming they can get the votes – would be Monday or Tuesday.

The Doc Fix Is On The Table Yet Again…

In Uncategorized on May 27, 2010 at 5:36 pm

Matthew DoBias of ( reports that:

House leaders are eyeing a legislative package that would increase physician Medicare payments over the next 19-months—until the end of 2011—but trim back some benefits for safety net health programs.

Under the measure, physicians would not see a 21% pay cut that’s scheduled to go into effect June 1, according to two sources with knowledge of the ongoing negotiations between House and Senate leaders.  If approved, it would be the third attempt to rework the troublesome sustainable growth-rate formula used to determine physician reimbursement. Previous attempts have proven too costly for some debt-wary lawmakers.  The package was expected to have been approved by the House Rules Committee Wednesday evening, clearing the way for final passage today.

House leaders huddled behind closed doors to help shape the bill’s framework, which attempts to patch the SGR while also extending unemployment insurance benefits as well as the timeline for a higher level of aid for COBRA premiums.  But those last two measures could be scaled back, ending in November rather than December—a move that would keep the unpaid provisions in the bill under $100 billion.  

Sources stressed that negotiations were fluid.  “We’re looking at the options,” Rep. Chris Van Hollen (D-Md.), a member of the House leadership team, echoed. Van Hollen said he expects the House to pass the bill before Memorial Day, though it remains unclear whether or not the Senate will support the package.

The Continuing Extension Act Vote Better Be Soon… The CMS Grace Period To Hold Claims Has Ended!

In Uncategorized on April 15, 2010 at 7:04 pm

Last night the Senate voted 60 to 40 to exempt the much-spoken-of-Baucus amendment (which says all spending legislation must be paid for) from the Continuing Extension Act (H.R.4851).  This significant vote moves the Senate closer to voting for bill itself.

In addition to dealing with the SGR, the underlying bill that senators are debating would temporarily extend funding for several federal programs that have expired, including unemployment benefits, COBRA health insurance subsidies for the unemployed, and the national flood insurance program.

Senate Democrats have been trying to pass the measure since before they left for a two-week recess, but failed to do so because of Republican opposition.

Republicans have blocked the bill because they don’t approve of passing a bill that isn’t paid for, while Democrats say the spending is for an “emergency” and is therefore not subject to Senate rules that require all spending be offset.

The underlying bill would extend most of the federal programs through April. However, with April being half over,  Sen. Baucus proposed another amendment which would extend the programs through May, the thought being to give Congressional leaders more time to work out an agreement on a bill passed by the House earlier this year, which would extend all of these programs for the remainder of 2010.

It is expected that Senators will vote on this second Baucus amendment and the underlying bill Thursday or Friday. If senators vote to extend the federal programs through May, the House would have to vote on the measure as well, which it is expected to do this week.

Most of the programs addressed in the bill — including the delay in doctor payment cuts — already expired April 1.

But doctors haven’t yet felt the blow from the April 1 pay cuts because, for the second time this year, the Centers for Medicare and Medicaid Services (CMS) stepped in and instructed contractors to hold claims for services performed on or after April 1 for the first 10 business days of the month. That grace period ended last night.

Still Awaiting A “Doc Fix” Update…. Detained In The Senate

In Uncategorized on April 14, 2010 at 3:37 pm

On Tuesday, April 13th, the Senate began consideration of the Continuing Extension Act (H.R. 4851), the House bill that has come to be known as the “doc fix,” which would provide a temporary extension of certain programs – most notably for the purposes of M.E.D.I.C., Inc.’s clients and others in the medical industry being the cancellation fo the 21.3% reduction in the Medicare Physician Fee Schedule. 

A unanimous-consent agreement was reached, however, providing for further consideration of the bill at approximately 10:30 a.m., on Wednesday, April 14, 2010.  Stay tuned…