Posts Tagged ‘Medicaid’

Primary Care Providers Should Have Seen Fee Increases in 2013!

In Uncategorized on August 22, 2013 at 9:11 pm

In 2013, family physicians, general internists, and pediatricians experienced some Medicare and Medicaid pay increases due to two final rules that had been released by CMS.

Here’s a brief look at each of the rules and the reimbursement-related changes they included:

Higher Medicaid Pay: As a result of one of the rules, released in early November, Medicaid payments to family medicine, general internal medicine, and pediatric medicine physicians will match Medicare levels in 2013 and 2014. The higher payments also apply to primary-care services provided by nurse practitioners and physician assistants who are under the supervision of a qualifying physician.

The pay hike is meant to encourage doctors to see additional Medicaid patients, for as a result of the Medicaid expansion portion of the Affordable Care Act, an additional 17 million more patients are expected to gain insurance in 2014.

While the pay increase is a “step in the right direction,” AAFP President and family physician Jeffrey Cain said in a statement that the temporary nature of it is troubling.  “Unless Congress acts to permanently extend and fund this provision, a sudden return to disparate and inadequate payment for primary-care services needed by Medicaid patients after only two years will again threaten to restrict their access to such needed services,” he said.  “Only by extending Medicaid parity with Medicare can we ensure that these Americans continue to have uninterrupted medical care in the future.”

New Payments: The 2013 Medicare Physician Fee Schedule final rule, also released in early November, establishes that primary-care physicians will receive separate payments for coordinating a patient’s care during the 30 days after a patient is discharged from the hospital. In total, these additional care-coordination payments are expected to increase family physician pay by 7 percent, and increase other primary-care physicians’ pay by 3 percent to 5 percent, according to CMS.   See the next section of this memo for a more detailed look at the coordination of care codes.

One of the critical issues raised in the Proposed Rule was what constitutes a primary care provider?  The PPACA identified the specialties of Family Medicine, General Internal Medicine and Pediatrics, as being “primary care.”  However, CMS opened the door to sub-specialists by proposing that they would consider sub-specialists within those general specialties as being “primary care” as well.  CMS specifically proposed that services provided by sub-specialists within the primary care categories designated in the statute would also qualify for higher payment. These would be sub-specialists recognized in accordance with the American Board of Medical Specialties (ABMS) designations.

The ABMS recognizes the following sub-specialties within the three statutorily referenced specialties:

 Family Medicine

Adolescent Medicine Geriatric Medicine
Hospice and Palliative Medicine Sleep Medicine
Sports Medicine  


Adolescent Medicine Pediatric Transplant Hepatology
Developmental-Behavioral Pediatrics Pediatric Medical Toxicology
Pediatric Emergency Medicine Pediatric Neonatal-Perinatal Medicine
Pediatric Pulmonology Pediatric Rheumatology
Pediatric Infectious Diseases Pediatric Nephrology
Pediatric Gastroenterology Pediatric Endocrinology
Pediatric Critical Care Medicine Pediatric Hematology-Oncology
Neurodevelopmental Disabilities Pediatric Cardiology
Sports Medicine Child Abuse – Pediatrics
Sleep Medicine Hospice and Palliative Medicine

Internal Medicine

Pulmonary Disease Rheumatology
Medical Oncology Nephrology
Infectious Disease Interventional Cardiology
Hematology Hospice and Palliative Medicine
Gastroenterology Geriatric Medicine
Critical Care Medicine Adolescent Medicine
Cardiovascular Disease Clinical Cardiac Electrophysiology
Sleep Medicine Sports Medicine
Endocrinology, Diabetes and Metabolism Advanced Heart Failure and Transplant
Transplant Hepatology  

During the public comment period, numerous medical specialty societies argued that CMS had inappropriately singled out ABMS as the only specialty Board CMS would recognize.  For example, the Proposed Rule excluded the American Osteopathic Association Board as well as the American Board of Physician Specialties (ABPS). 

After reviewing the comments, CMS has decided to expand the Boards (and associated sub-specialties) they will recognize.  CMS will now recognize both the AOA specialty designations under the heading of Family Practice, Internal Medicine and Pediatrics, as well as the ABPS specialty designations within the three recognized specialties. 

Finally, CMS will permit physicians who are not Board Certified, to “attest” that they provide primary care services.  For physicians who wish to “attest” they must demonstrate that at least 60% of the services they bill to Medicaid are for the codes designated as “primary care” codes.


Think That You Are Ineligible For Stimulus Funds??? Check Here!

In Uncategorized on April 1, 2011 at 7:09 pm

As the timing ticks away for practices to select, implement and meaningfully use a certified EHR so as to take advantage of the maximum ARRA EHR stimulus rebate, perhaps the most pressing question being asked by providers is whether they are even eligible for ARRA EHR stimulus funds???

Every provider that accepts Medicare qualifies for some portion of stimulus funds.  The percentage of a provider’s Medicare patient base is not a factor in determining eligibility for the Medicare stimulus finds.  Rather, it is the Medicare allowable charges that is key.  As long as a providerr has one allowable charge, then he/she is eligible for the stimulus funds.  Then the question becomes how much of the annual stimulus rebate is he/she entitled to receive.  There is a simple formula for determining this:

Total annual Medicare Allowable Charges by provider divided by $24,000

That formula will result in the percentage of Medicare stimulus funds a provider is entitled to receive, up to 100%, which represents the the maximum percentage of the annual stimulus funds that can be earned during a particular year.

For example: 

  • if a provider’s allowable charges total $12,000 in his/her first year meaningfully using a certified EHR, then the physician qualifies for 50% of the annual stimulus funding ($12,000/$24,000).  In 2011 the funding is $18,000, so that provider would receive $9,000 of ARRA stimulus funds   
  • if a provider’s allowable charges total $24,000 in his/her first year meaningfully using a certified EHR, then the physician qualifies for 100% of the annual stimulus funding ($24,000/$24,000).  In 2011 the funding is $18,000, so that provider would receive $18,000 of ARRA stimulus funds

Essentially, any provider whose Medicare allowable charges meet or exceed $24,000 will receive 100% of that year’s ARRA rebate incentive (up to a maximum total of $44,00 throughout the life of the program).  This figure can also be arrived at by multiplying total Medicare allowable charges by 75%…  ARRA rebate amount is the product of that equation or 18,000 – whichever is less. 

NOTE TO MEDICAID PROVIDERS:  If you have a measurable Medicaid population — at least 30% of your patient population (or 20% if a pediatrician) — then the Medicaid EHR Incentive Program, which is offered and administered voluntarily by states and territories, may be of interest as an alternative to the Medicare program (must choose between the two programs).  To qualify for Medicaid incentive payments, Medicaid eligible professionals must adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology in the first year of participation, and successfully demonstrate meaningful use in subsequent participation years, just like in the Medicare program.  However, under the Medicaid program, participants can receive up to $63,750 over 6 years (as opposed to $44,000 over 5 years):

Check with your state’s Medicaid program to see if the rebate program has been implemented yet, as it is a state-by-state roll-out.