Medicare Compliance & Reimbursement

If you were anxious that you’ll face a 21 percent reimbursement cut on April 1 if Congress doesn’t vote to override it, there is hope for now. You stand to not only get a reprieve to the cut, legislators aim to fix the Medicare payment formula instead of continuing to offer temporary fixes to the Sustainable Growth Rate (SGR) issue.

Background: Congress has passed 17 SGR “patches” since 2002, which has made both legislators and physicians wary about simply moving the problem forward yet again. Eliminating the SGR would be welcome by most Medicare providers, but the price of saying goodbye to these temporary “doc fixes” may be too steep for some members of Congress.

The U.S. House of Representatives passed H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015, by an overwhelming majority on March 26 — 392-37 with 4 abstaining — to permanently repeal the flawed SGR payment formula for Medicare Part B providers. The Senate plans to take up H.R. 2 when they return from a 2-week recess, according to the Wall Street Journal.

In the proposal: If signed into law, H.R. 2 will give 0.5 percent annual boost to Medicare pay for five years, after which practitioners would get bonuses based on quality of care rather than the number of procedures they administer. The cost of the plan would reportedly amount to about $200 billion over the next decade, and some of that cost could be passed on to higher-earning Medicare beneficiaries.

Medical associations voiced optimism about the potential for SGR elimination. “We remain optimistic that our collective voices will make a difference and that Congress will finally act on eliminating the SGR,” said Robert M. Wah, MD, president of the AMA, in a March 16 statement. “It’s time to end this annual game of kicking the can down the road that is unfair to patients and physicians and wastes taxpayer dollars.”

Unnecessary Services Lead to $5.3 Million Repayment for NY Doctor

When coding and billing experts continually remind practices to “put medical necessity first,” they aren’t just blowing smoke. Without a medically necessary reason to perform your services, you could be facing jail time.

A New York physician is learning that lesson the hard way this week after pleading guilty to billing Medicare for $14.2 million in claims for medically unnecessary treatments, the Department of Justice (DOJ) reported on March 6. The doctor has to pay nearly $5.4 million back to the government, and will face sentencing later this year.

The doctor admitted that he and other practitioners at his clinic submitted “false and fraudulent claims to Medicare for medically unnecessary vitamin infusions, physical therapy and occupational therapy that did not qualify for reimbursement by Medicare,” the DOJ said in its statement.