# Sequestration and Medicare Advantage



## alannae (May 3, 2013)

Has anyone tackled the issue of dealing with their Medicare Advantage plans and the sequestration reduction? One of our smaller MA plans is trying to get us to sign a contract amendment to accept the 2% reduction but our other MA plans have just taken the reduction (and are not applying it the same way as Medicare) without a contract amendment. Has anyone looked into this?

The best we can tell so far is that the wording in our contracts for the big, national (you'd all recognize them) MA plans protects them and allows them to reduce our payments by including the phrase 'payment system' and not just referring to 'medicare fee schedule'. The small MA plan I referred to only references 'medicare fee schedule' when outlining how we will be paid.

It bothers me that they are able to push off all of the proposed loss of profit onto us. Anyone out there considering fighting this on any level?

Thanks for any thoughts!

Alanna, CPC


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## beckycmbs (May 7, 2013)

The MA's are supposed to be taking the 2% cuts also.


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## alannae (May 7, 2013)

Do you have a reference for that? Everything I've found only refers to Medicare Part A and B. I've found nothing that says "Part C" or Medicare Advantage or that states these programs are included in Part A/B in this instance.


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## Teresa Collins (May 8, 2013)

alannae said:


> Do you have a reference for that? Everything I've found only refers to Medicare Part A and B. I've found nothing that says "Part C" or Medicare Advantage or that states these programs are included in Part A/B in this instance.



I do not have a reference; however, we have received EOBs from United Healthcare and Humana with the 2% reduction noted.  

I hope this helps.


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## annawade13 (May 9, 2013)

beckycmbs said:


> The MA's are supposed to be taking the 2% cuts also.



I don't know about "supposed to" but I did get an email from Humana saying they were jumping on the reduction bandwagon. My boss said IF they are getting reimbursed less from Medicare for their MA programs it would make sense to try to "pass the buck," but when you hear about the record profits some of these insurance companies post, I think there's definitely room for doctors to fight back.

Does anyone happen to know if Medicare's MA payments were reduced with sequestration? Or just the providers?

A certain phrase about killing the goose that lays the golden eggs comes to mind...


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## debwoods65 (May 9, 2013)

Very interested in hearing more about this.  We have seen cuts on our Humana EOBs as well.  Not sure what our interim practice manger is doing about it.  She was not sure what it was all about at the outset.


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## alannae (May 9, 2013)

We have seen cuts on our Humana eobs but they are not being applied the same way as our Medicare contractor is applying the cuts. Humana is not applying the cuts to all codes, only physician fee schedule code (ie not drug codes). Novitas is applying the cuts to every code.

We have another Medicare Advantage plan that is requesting we sign a contract amendment to include any legislated cuts (ie sequestration and any other stuff they throw at us) so that they can also cut our payments. That amendment is what started us asking questions and looking around for something that said the Medicare Advantage plans are required (or even allowed) to pass these cuts on to the providers.

So far from the companies we've only gotten some uninformed baloney from our provider reps. 

Alanna


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## camillecoder@hotmail.com (May 16, 2013)

This issue was discussed today on the Decision Health/Part B News listserv and this was the link provided.

http://www.elsevierbi.com/~/media/S...DAILY/2013/May/CMS Sequestration Guidance.pdf


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## alannae (May 17, 2013)

Thanks, Camille. 

I found what I was looking for on page 3. That echos an article that was sent to my manager yesterday from InsideHealthPolicy.com (I don't have a link for it, sorry).

So, it seems from this that the Medicare Advantage plans must honor our contracts as they are and cannot pass the cuts they will receive onto us. 

Has anyone else contracted their provider reps or anyone else?

Alanna


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## alannae (May 17, 2013)

My manager just got an email from a big cheese with CMS stating that they have received many inquiries about Medicare Advantage and sequestration.

Bottom line is that if you are contracted with the Medicare Advantage plan, that contract prevails (ie they cannot deduct the 2% unless the verbiage in your contract allows it). CMS cannot override private contracts.

He also attached the same memorandum that Camille posted earlier.

We will be continuing to pursue repayment of the money that has been deducted from our payments so far.

Anyone else have any other experiences?


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## alannae (May 23, 2013)

I just received a newletter from COA (Community Oncology Alliance) that includes this:

Check Your Medicare Advantage Contracts!!!
We have posted a memo from CMS that basically says that the 2% sequester cut cannot be automatically "passed along" by MA plans, as some MA plans have apparently done. As CMS has guided, the ability of MA plans to make any payment cut is based solely on the contract between the plan and the provider. So, read your contracts carefully. Don't assume because CMS has made the 2% cut to Medicare FFS payments that MA plans have the same right. They can only make a payment cut to the extent that their contract allows them to make cut payment, sequester or no sequester.

COA is not providing any type of legal advice. We are just suggesting that you read your MA contracts and seek legal counsel, as many practices have done. Click here to access the guidance memo that CMS issued to MA plans.



Here is the link to the CMS memo mentioned
http://library.constantcontact.com/...1752271023-173/CMS+Sequestration+Guidance.pdf


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## julietshaw (Jul 10, 2013)

*All medicare is a,b,c,d included*

http://www.fas.org/sgp/crs/misc/R42050.pdf

This is such lovely packet of information.  It explains the caps on medicare's ability to cut more than 2%...

and it looks like the rest of the 4% projected cut will occur over the next year or so.

I am so glad that everyone shares information here--it's hard to help medicare patients understand their deductibles much less the fact that these cuts are hitting the Doc's and not them...

Juliet


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## rleigeb (Sep 12, 2013)

*Mutually exclusive codes for MA*

We have been seeing the 2% reduction on our mutually exclusive V codes for hearing aids and services. We have appealed this as these codes are not payable by medicare so why can medicare cut 2% of a code they don't even recognize or pay on?


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## ABridgman (Sep 12, 2013)

Teresa Collins said:


> I do not have a reference; however, we have received EOBs from United Healthcare and Humana with the 2% reduction noted.
> 
> I hope this helps.



Not only is United Healthcare withholding it on ERA's...they are even hiding it in the coding...not taking it as a CO-223 like everyone else...instead, changing their CO-45 to a PI-45 and putting their normal contractural discount together with the Sequestration cut, which I think is awful sneaky.

Personally, as a small business owner, who gets paid on percentage...I wonder if Congress knows or cares there are small business owners, billers like myself...who are taking a cut in pay over this.

And I don't see MY Congresscritter taking any pay cut!


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