TopMed-Pro Management, Inc.
Medical Practice Management & Consulting
NewsWire                                                                                              May 2010
In This Issue
Medicare Claims Filing is Now 1 Year!
Your Medicare Participation Options
Medicare Claims Filing is Now 1 Year !
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), which amended the time period for filing Medicare fee-for-service (FFS) claims as one of many provisions aimed at curbing fraud, waste, and abuse in the Medicare program.
The time period for filing Medicare FFS claims is specified in Sections 1814(a), 1835(a)(1), and 1842(b)(3) of the Social Security Act and in the Code of Federal Regulations (CFR), 42 CFR Section 424.44. Section 6404 of the PPACA amended the timely filing requirements to reduce the maximum time period for submission of all Medicare FFS claims to ONE calendar year after the date of service.
The following rules apply:

Date of Claim

Deadline to Submit

On or after Jan. 1, 2010

Within one calendar year after the date of service.

Before Jan. 1, 2010:

Dec. 31, 2010

  Before Oct. 1, 09

Follow pre-PPACA timely filing rules*

  Oct. 1, 09 - Dec. 31, 09

Dec. 31, 2010

* Under pre-PPACA rules, Medicare carriers can accept claims for dates of service from Oct. 1, 2008, through Sept. 30, 2009.  Claims filed beyond one year for the first time of the service date will be automatically reduced by 10%.
"If we all did the things we are capable of doing, we would literally astound ourselves." 
                Thomas A. Edison
Quick Fact
Source of Annual Patient Services Revenue:
Patient Self-Pay       10.9%
Commercial Payors  51.8%
Public Insurance       37.3%
  (Medicare, MediCal,etc.)
Source: MGMA Survey
Consultation Codes - How Some Non-Medicare Insurances Are Reacting...
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Your Medicare Participation Options
With Medicare's 21.2% cut looming, many physicians are frustrated with the whole process. Since 2001, Medicare payments have only increased by 1%, whereas physician costs have risen by 22%!  To help physicians make informed decisions on their participation with Medicare, we have listed the three available options about Medicare participation.
Participation (PAR):
PAR physicians agree to take assignment on all Medicare claims, which means that they must accept Medicare's approved amount -- 80% paid by the government after the deductible is met, plus a 20% co-payment -- as payment in full for all covered services for the duration of the calendar year. The deductible for 2010 is $115.50.
Medicare provides several incentives for physicians to participate:
  • The Medicare approved amount for PAR physicians is 5% higher than the Medicare approved amount for non-PAR physicians.
  • Directories of PAR physicians are provided to senior citizen groups and individuals who request them.
  • Carriers provide toll-free claims processing lines to PAR physicians and process their claims more quickly.
Nonparticipation (Non-PAR): Non-PAR physicians can file non-assigned claims for Medicare patients on a case-by-case basis, in return for fees that are set at 95% of Medicare-approved amounts. But non-PAR physicians can balance-bill patients more than the Medicare approved amount up to a capped amount. This capped amount is known as the "limiting charge".  Limiting charges for non-PAR physicians are set at 115% of Medicare approved amount for non-PAR physicians.  However, because Medicare approved amounts for non-PAR physicians are 95% of the rates for PAR physicians, the 15% limiting charge is effectively only 9.25% above the PAR-approved amounts for the services (95% of $115 is $109.25).
Further, Medicare pays the patients directly for services billed by non-PAR physicians. Doctors considering becoming non-PAR for an upcoming calendar year are advised to consider potential collection costs and bad debts when projecting revenue.
Click here to see an example of the difference on accepting assignment as a PAR vs. non-PAR physician.
Private contracting: Provisions in the Balanced Budget Act of 1997 give physicians and their Medicare patients the freedom to privately contract to provide health care services outside the Medicare system. Private contracting decisions may not be made on a case-by-case or patient-by-patient basis, however, once physicians have opted out of Medicare, they cannot submit claims to Medicare for any of their patients for a two-year period.
To privately contract with a Medicare beneficiary, a physician must enter into a private contract that meets specific requirements (request a sample private contract).  In addition to the private contract, the physician must also file an affidavit that meets certain requirements (request a sample affidavit). To opt out, a physician must file an affidavit that meets the necessary criteria and is received by the carrier at least 30 days before the first day of the next calendar quarter. There is a 90-day period after the effective date of the first opt-out affidavit during which physicians may revoke the opt-out and return to Medicare as if they had never opted out.
Source: AMA
Also, click here to see providers who have opted out of Medicare in Southern California.
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.
Med-Pro Management, Inc.

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