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Medicare Reimbursement in Limbo Until April 13, as SGR Lingers

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Physicians who often refer patients to therapists may be wondering how to charge for Medicare services, now that the sustainable growth rate (SGR) formula’s 21% rate cut ostensibly is in effect. The cut could become null by April 14, however, if the Senate approves a bill to repeal the SGR when it reconvenes April 13.

If the bill is approved April 13, it could ultimately mean the ongoing maneuvering around SGR, including billing changes, will be meaningless since the Centers for Medicare and Medicaid Services (CMS) cannot pay clean electronic claims any sooner than 14 calendar days after receipt (29 days for hard copy claims), according to a report by Medscape.

The bill, known as the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015,  would enable CMS to retroactively cancel the 21% rate reduction if it is approved by the Senate and signed by President Obama by April 14. The Medscape article notes that once signed into law, MACRA would also pay all claims for services performed after March 31 at pre-April levels.

Do This, Not That

For providers, physicians especially, who are confused about how to bill for services in the interim, Medscape has reported some advice that may help successfully navigate the confusion. First, among those recommendations, is for physicians to not voluntarily mark down Medicare claims by 21% for services performed on and after April 1, counting on getting back the difference once the Senate approves MACRA. The following example published by Medscape outlines why that approach may fail:

“Consider a physician who performs a hypothetical service that Medicare approves for $100. When the physician bills for this amount, the program pays him or her 80%, or $80, with the patient owing the remaining 20%, or $20, in the form of coinsurance (this assumes the annual deductible has been met). However, if the physician marks down the submitted charge 21.2%, to $78.80, Medicare ignores its standard $100 rate and pays the physician 80% of $78.80, or $63.04, Moore told Medscape Medical News. The patient would owe 20% of $78.80, or $15.76. If the SGR repeal bill is eventually passed by the Senate, CMS would not reprocess such a claim at pre-April rate levels and send the physician the difference between $80 and $63.04.”

Alternately, there are two actions recommended to providers that could shape more positive outcomes. One of these actions is to continue submitting Medicare claims at the old rates and hope the Senate passes the repeal bill by April 14.

The other recommended action is for physicians to hold on to Medicare claims for services rendered beginning April 1, and await final passage of the repeal bill — or a temporary delay of the 21% cut — before submitting them.

[Source: Medscape]