Pediatric Coding Alert

Know your state's Medicaid regs front and back because you may see an increased Medicaid patient population.

Although the Affordable Care Act (ACA) was signed into law over two years ago, it's still a hot topic and is back in the news this month after the Supreme Court's latest ruling that the law is Constitutional. But pediatricians still have questions about what the ACA means for their day-to-day operation. Today we've got the top three facts that will help you see the law's impact on your daily practice.

Fact 1: You May See More Medicaid Patients
With the law's emphasis is on health insurance, it's clear that the patients who can't afford to buy health insurance may become Medicaid patients. Therefore, you may see your ranks of Medicaid patients swell as the years pass. If your practice isn't already familiar with your state's Medicaid guidelines, this is the time to start getting to know how to find policies and submit claims to your state Medicaid program.

Uninsured may still present: Despite the law's intent on insuring all Americans, some patients may still remain uninsured. "Since the power to enforce the Medicaid limits on the states was not included in the decision, there may still be 'working poor' falling into a crevice," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

"The ACA says 133 percent of the federal poverty level should be covered by Medicaid, but any state may decide to not cover up to 133 percent," Cobuzzi says. "These patients may find they can only 'afford' to pay the 'tax' (that is the lowest cost alternative in the short run)." Therefore, there will be an underserved population, between what the states determine what they will cover with Medicaid and 133 percent of Federal Poverty level.

Tip: You should not only familiarize yourself with the Medicaid regulations, but be ready to continue treating uninsured patients. Many practices offer cash discounts or payment plans for these families.

Fact 2: Look for Medicaid E/M Pay Boost

Because you will most likely be seeing more Medicaid patients, you will be pleased to hear that Medicaid payment for your E/M services will rise next year, thanks to provisions in the ACA.

"Starting in 2013, Medicaid payment for most E/M codes will be at Medicare equivalent levels, a significant increase for those providing access to care for these vulnerable patients," says Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

Follow Pediatric Coding Alert as we move into 2013 to determine what those rates will be and how quickly Medicaid plans begin to adapt to the new regulations.

Fact 3: Compliance Plans Will Eventually Become Required. Although the ACA touches on the importance of compliance plans, those plans are still optional at this point. "Under the ACA, a compliance plan that has the 'core elements' which will be established by the Department of Health and Human Services and the Office of Inspector General will become a requirement," Cobuzzi says. "This is a huge change. First we will need to find out what the core elements will be."

In addition, compliance requirements will impact your Medicaid patients as well, says Scott A. Memmott, Esq., with Morgan, Lewis & Bockius, LLP in Washington, DC. "State Medicaid plans must require providers and suppliers to establish a compliance program that contains the same core elements that HHS, in consultation with HHS-OIG, eventually will establish with respect to the Medicare program," Memmott says. "So even pediatricians who see no Medicare patients but do see Medicaid patients will be subject to mandatory compliance program requirements that will come from their state Medicaid plan."

The Department of Health and Human Services will likely be developing the compliance program's elements over the next year or more, but in the meantime, you should continue to pursue your practice's compliance objectives by creating a compliance plan tailored to your needs. Future issues of Pediatric Coding Alert will offer step-by-step advice on how to create and implement these plans.