Reimbursement success in 2013 may hinge on devil in the details


The ball dropped over Time Square. Confetti rained down on house party occupants and bar crawlers the nation over. Midnight kisses came and went in minutes and by dawn the next day, the first day of 2013, physicians were back to treating the same wounds and contemplating the same pending regulations 2012 left behind.

The year prior left some pretty massive footprints for 2013 to fill — the Affordable Care Act was approved by the United States Supreme Court and became a more permanent healthcare tapestry when Barack Obama was re-elected president on Nov. 6. The final physician fee schedule was published on Nov. 16. Congress squabbled over revoking pay cuts of 26.5 percent for physicians who treat Medicare patients, then finally, on Jan. 2, pitched legislation that would back providers away from that ledge.

Despite such progression, 2013 is shaping up to be an equally contentious year, if not more eventful, regarding financial matters.

As American Medical Association President Jeremy A. Lazarus, MD, noted in a statement regarding the last-minute pay cut aversion, “Congress’ work is not complete; it has simply delayed this massive, unsustainable cut for one year. Over the next months, it must act to eliminate this ongoing problem once and for all.”

Because of the American Taxpayer Relief Act (ATRA) — where the pay cut aversion was tucked away — as well as other veiled factors important for physicians to know reimbursement-wise going forward, Elizabeth W. Woodcock, MBA, FACMPE, CPC, spoke openly about the foothills erected along the horizon in 2013 in a Navicure-sponsored presentation delivered on Jan. 9.

Regarding ATRA, Woodcock pointed to the following basic take-home points as paramount to the physician's pocket:

  • “Zero Percent” Update; Conversion Factor set at $34.0230
  • Extension of the Work Geographic Practice Cost Index (GPCI) floor
  • Carriers given until Jan. 23 to post rates

  • Claims processing may be delayed until Jan. 16

In light of the second point, Woodcock remarked: “Folks, you really dodged a big bullet by having this extension of the Work GPCI floor.”

But although one bullet was dodged, many physicians are yet to be out of firing range; some Medicare rates will be subject to change moving forward with RVU alterations, Woodcock said. In this realm, certain practice types prevailed over others (as can be seen the figure below).

Impact of RVU Changes

Winners Losers
Family Practice   (7%) Radiation Oncology  (-7%)
Geriatrics  (5%) Neurology  (-7%)
Internal Medicine (4%) Pathology  (-6%)
Pediatrics (3%) Physical Medicine (-4%)
Allergy/Immunology  (3%) Radiology, Interventional Radiology, Nuclear Medicine, Ophthalmology   (-3%)
All other physician specialties are b/w -2 and +2 %. Information from Woodcock and Associates.

Woodcock listed the below as additional high points on the Medicare 2013 horizon that doctors and practice managers should consider:

  • Announcement that the value-based modifier begins in 2015, but only for groups with >100 physicians.

  • Extension of multiple procedure payment reductions (MPPR), including some ophthalmic and neurologic imaging.
  • Expansion of the list of approved Medicare telehealth services, to include behavioral health assessments, as well as alcohol abuse assessments and interventions.
  • Targeting of DME abuse, requiring a related face-to-face encounter before a DME order can be processed for orders written on or after July 1, 2013.
  • No changes to Practice Expense (PE), Malpractice (MP) GPCIs or Work GPCIs because of Geographic Practice Cost Index alterations.

As a parting word of cautionary advice, Woodcock reminded participants about the inherent nature of government “voluntary” programs.

“None of the government’s incentive programs are mandatory; however if you decide not to participate in the “voluntary” programs you will indeed be penalized,” she said.