Med-Pro Management, Inc.
Medical Practice Management & Consulting
NewsWire                                                                                January 2010
In This Issue
Sign-up with Medicare or Lose Getting Paid...
CMS Instructs its Contractors to Hold All Payments...
Sign-up with Medicare or Lose Getting Paid

Centers for Medicare and Medicaid Services (CMS) announced on Nov. 23 that it would delay implementation of new rules and edits that give Medicare the authority to reject claims for services or supplies when the ordering physician or health care professional is not enrolled in the Medicare Provider Enrollment, Chain, and Ownership System, or PECOS. The agency is delaying implementation of the new policy until April 5, 2010

There are several flaws with Medicare's new rules.  As of July 2008, there were 793,346 physicians and other health care practitioners enrolled in Medicare.  According to data from an October 2009 Office of Inspector General report, there were 559,235 physicians and other health care practitioners in PECOS. Therefore, as many as 200,000 or 30 percent of all Medicare physicians and other health care practitioners are not in PECOS and will need to re-enroll. 

Another shortcoming is that some providers who commonly refer Medicare patients or order services for them do not typically enroll in Medicare.  For instance, some residents may not be enrolled in Medicare, but will certainly be ordering or referring providers for Medicare purposes.  Likewise, dentists may be ordering/referring providers, but otherwise have no reason to enroll in Medicare.  CMS staff indicated that they will soon be issuing instructions to deal with the dentist issue, but one wonders why CMS didn't think of doing that before it started implementing the edits in question. 

Finally, physicians have no practical or convenient way to check whether the physicians or other health care practitioners who refer them patients with orders or referrals are included in PECOS or other contractor enrollment records. CMS has promised to address this particular concern by making available a list of eligible referral providers before January 2010, but again, one is left to wonder why they did not do so before implementing the edits.

"The best way to predict your future is to create it."                   Abraham Lincoln
Spending time with payers?
3 hours per week
The amount of time physicians spend interacting with health insurance plans

Converted to dollars, the total staff time spent interacting with health insurance plans systemwide per physician, per year, on average.

Source: MGMA/Health Affairs
DHCS (Medi-CAL) has announced a new contract to ACS

CMS has designated a NEW modifier "AI" (Principal Physician of Record).
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CMS Instructs its Contractors to Hold All Payments...

On Dec. 21, the president signed into a law the Department of Defense appropriations bill that freezes the Medicare conversion factor for 60 days. This language addresses only the conversion factor; and all other 2010 policy changes to the Medicare program become effective on Jan. 1.

Due to ongoing healthcare reform negotiations, the Centers for Medicare & Medicaid Services (CMS) recently announced that it would hold all Part B claims until Jan. 15, and that the Physician Annual Participation Enrollment Program would be extended from Jan. 31 to March 17. In the announcement, CMS said: 

"[It] is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare physician fee schedule, beginning January 1, 2010. In this regard, CMS has instructed its contractors to hold claims for services paid under the Medicare Physician Fee Schedule (MPFS) for up to the first 10 business days of January (January 1 through January 15) for 2010 dates of service. This should have minimum impact on provider cash flow because, by law, clean electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the date of receipt. Meanwhile, all claims for services delivered on or before December 31, 2009, will be processed and paid under normal procedures.
The holding of claims allows Medicare contractors time to receive the new, updated payment files and perform necessary testing before paying claims at the new rates. CMS has instructed contractors to begin processing claims at the new rates no later than January 19, 2010. Please note that most contractors are closed on the January 18 Martin Luther King Day holiday. Therefore, even absent a new update, most claims likely would not have been paid any sooner than January 19, 2010, given the aforementioned statutory 14-day payment floor.

CMS has extended the 2010 Annual Participation Enrollment Program end date from January 31, 2010, to March 17, 2010- therefore, the enrollment period now runs from November 13, 2009, through March 17, 2010.
The effective date for any Participation status change during the extension, however, remains January 1, 2010, and will be in force for the entire year.
Contractors will accept and process any Participation elections or withdrawals, made during the extended enrollment period that are received or post-marked on or before March 17, 2010.
In addition, be on the alert for more information about other legislative provisions which may affect you."

If you are interested to find out more about any of the topics mentioned, please do not hesitate to send us an email at or call us at (888) 549-1713.
Razmik Sarkisian, M.S.H.A.
Chief Operating Officer
Med-Pro Management, Inc.

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