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New Preventive Benefits & Physician Payment Increases in Final Physician Payment Rule
On November 3, 2004, the Centers for Medicare & Medicaid Services (CMS) announced Medicare's final rule for physician payments for 2005. The 2005 rule contains new benefits and higher payments for preventive services. The expanded benefits and increased payments will become effective on January 1, 2005.
The final rule includes reimbursement for preventive measures. For example, a new “Welcome to Medicare Physician” will be covered. Physicians will be allowed to bill and be paid separately for a screening electrocardiogram and physical exam. Physicians may also bill for a more extensive office visit, performed at the same time as the physical, so long as the services are medically necessary.
The final rule significantly increases payment for vaccinations and other types of injections. This action is in direct response to AMA’s Drug Administration Workgroup’s effort to ensure adequate payment for drug administration services. For example, payment for administration of the influenza vaccine will increase from $8 to $18.
PHYSICIAN PAYMENT UPDATE: SUSTAINABLE GROWTH RATE (SRG) FORMULA
Medical practice costs continue to outstrip Medicare physician payment increases. Had Congress not acted in 2003 to enact stop-gap legislation physicians would have received a 4.5% cut in payments in both 2004 and 2005. Instead, physicians received a 1.5% increase in those years. The fundamental problem is the method used to calculate physician payments, the sustainable growth rate (SGR) formula. Payment rates are set annually based on the SGR. The SGR relies, in part, upon the national gross domestic product (GDP). However, the GDP bears no relationship to health care needs or physician's increased practice costs. In particular, increased medical liability insurance costs are not appropriately captured in the formula. Until this flawed formula is improved or replaced, Medicare payments will continue to lag. MSNJ and AMA are working to have the flawed formula corrected.
For more information, visit AMA's web site at www.ama-assn.org. Members are encouraged to contact their federal legislators directly to urge them to fix the formula. This can be done from the AMA web site. This issue is important not only to Medicare providers, but also to other physicians because the Medicare payment schedule influences other payer schedules.
Fee Schedule
Interactive Voice Recording (IVR) and New Phone Number
In October Empire Medicare Services introduced an automated system, Interactive Voice Response (IVR). IVR is an interactive voice system that allows physician providers to obtain information through voice commands, rather than entering a complicated combination of numbers on the telephone keypad. Providers can now obtain eligibility information without speaking to a representative. In addition, providers can obtain claim status and patients’ deductible information.
The new phone number for Medicare Part B New Jersey providers is: 1-877-567-9235. MSNJ will advise members when the list of IVR information is posted on Empire’s web site.
Mediation
The Centers for Medicare & Medicaid Services (CMS) recently implemented a mediation program for resolving non-confirmed quality of care complaints filed by Medicare patients involving a Medicare-certified practitioner or healthcare provider. HQSI (Formerly PRONJ) is the quality improvement organization responsible for implementing CMS's mediation program in New Jersey. HQSI will review the matter and, if no quality of care concern is found, it may be eligible for mediation. HQSI believes that resolution of issues by mediation may reduce the risk of malpractice claims.
For more information, call Kathleen Farber, RN, or Beth Pellicore, RN, at 732-238-5570, or visit the HQSI web site at: http://www.hqsi.org/.
Comprehensive Error Rate Testing Program (CERT)
Physicians are urged to comply with requests from the Centers for Medicare & Medicaid Services (CMS) under the Comprehensive Error Rate Testing program.ÿCERT, introduced in August 2000, will improve the processing and medical decision making involved with payment of Medicare claims. The program serves as the basis for calculating a national error rate for Medicare claims. If you fail to respond to a record request CMS requires Empire to collect overpayments on the claims. To avoid this, providers should respond immediately to any CERT records request. For additional information, send an e-mail inquiry to NJLPET@empireblue.com.