Congress Passes Permanent Fix for Physician Medicare Payments

With the Senate passage of the Medicare Access and CHIP Reauthorization Act of 2015 (also referred to as the SGR bill or the Doc Fix), certain risks related to the billing of Medicare Part B services will have been resolved.  The -21.2 percent rate adjustment that was to be applied for Part B procedures as of April 1, 2015, including therapy services, was eliminated. Provider fee schedule rates will remain unchanged until July 1, 2015 when a 0.5 percent rate adjustment will be applied.  The hard $1,940 Part B therapy cap without exceptions that would have applied for rehabilitation services as of April 1, 2015 was also eliminated. The process to request exceptions to the cap has been extended through December 31, 2017.  

AHCA sent a letter with FAQs and conducted member calls on March 30 to provide an update on the status of the SGR bill legislative delay that described two specific risks operators faced from April 1 until the date of enactment of the Doc Fix.  At the time, AHCA provided two specific recommendations to consider:  1) "Operators hold any Part B claims with dates of services on or after April 1 until it is clearer what will happen in the Senate" and 2) "Operators issue Advance Beneficiary Notices (ABNs) to beneficiaries needing Part B therapy services beyond the $1,940 threshold as of April 1, 2015." With the passage and enactment of the Doc Fix, these recommendations no longer apply.

AHCA is updating its recommendations to operators and encourages a return to normal operating procedures related to these two soon-to-be resolved risks:

1. AHCA recommends that operators submit claims on the usual schedule, as the Centers for Medicare and Medicaid Services (CMS) has indicated that Medicare Part B claims with dates of service on or after April 1, 2015 will be paid per the provisions of the SGR Bill. Note, however, that CMS has explained that "[w]hile the Medicare Administrative Contractors (MACs) have been instructed to implement the rates in the legislation, a small volume of claims will be processed at the reduced rate based on the negative update amount. The MACs will automatically reprocess claims paid at the reduced rate with the new payment rate."

2. AHCA recommends that it will no longer be appropriate for providers to issue advance beneficiary notices (ABNs) to beneficiaries receiving medically-necessary services above the $1,940 therapy caps since providers can use the exceptions process for therapy services above the threshold. More information about therapy cap related ABNs when exceptions apply can be found on the CMS website.