Many questions have come to the chapter about participating in Medicare. Here is the information about Medicare for practices to make individual decisions about business models. There are three status types with Medicare. Participating When a provider is par with Medicare they must accept assignment. Medicare will allow the full fee schedule amount and the patient pays the 20% copayment or deductible. The billed amount over the fee schedule amount must be written off. This amount cannot be collected. Non-Participating When a provider in non-par with Medicare they are not required to accept assignment. The non-par fee schedule is 95% of the par fee schedule. If assignment is accepted, Medicare will pay 80% of the allowed amount and the patient pays the 20% copayment or deductible. Keep in mind, the fee schedule is 5% less than the par fee schedule. If a provider does not accept assignment they may bill the patient 115% of the non-par fee schedule. This is referred to as the limiting charge level (LCL). The patient will be reimbursed by Medicare. Keep in mind, in theory you are collecting the LCL at the time of service before the patient gets paid. If you do not collect at the time of service you will have to bill the patient and hope they pay you when they get paid. Keep in mind, when Medicare pays the patient, the paid amount will be 80% of the allowed amount and the patient is responsible for 115% of the allowed amount. In these economic times it is difficult to collect balances from patients for copayments and deductibles much less, the full amount LCL that is owed. I am not sure that collecting 9.25% more is worth the risk. Keep in mind, the non-par fee schedule has the same cuts in RVU’s and conversion factors as the par fee schedule. Opt-Out If a provider does not want to be affiliated in any way with the Medicare program they may Opt-Out. When a provider Opts-Out they no longer have any affiliation with Medicare. The patient is responsible for 100% of the payment amount. The provider can charge whatever they determine to be fair market rates. Medicare is not billed and the patient in essence Opt-Out of Medicare when seeing that provider. Providers must provide notice of Opting-Out for a time period prior to Opting-Out. If I recall properly it is 30 days prior to the end of the quarter prior to the desired effective date of Opting-Out. If a provider Opts-Out they cannot be readmitted to the Medicare program for two years after they see their last Medicare patient unless certain criteria is met. This includes refunding to the patient any amount collected above the LCL. A link to Opting Out from the Medicare Manuals is below. http://www.cms.hhs.gov/Transmittals/downloads/R92BP.pdf Keep in mind that most managed care contracts require a provider have an active Medicare provider number. If not, the provider cannot be contracted with that payer. This would cause the provider to be rendering services out of network which could discourage patients from getting treatment from that provider. In summary, in a perfect scenario if all cardiologist in a community were to Opt-Out this could have a significant impact on Medicare making changes and managed care changing their payment rates however, unless all cardiologist Opt-Out and only half do, this will not have an impact. I would think it is safe to assume if a limited number of cardiologist Opt-Out this will not have an impact on CMS changing the policy. BILLING & CODING SEMINAR SPONSORED BY THE FCACC AUGUST 21, 2009 Noon - 5:00pm Click here to register! Seats are still available. TOPICS TO BE COVERED MEDICARE RULE CHANGES PROPOSED FOR 2010: Payment cuts of 21.5% Accreditation required for Diagnostic Procedures Elimination of Consultation Codes Malpractice cost calculation changes Decrease in the Technical component of diagnostic test **Experts have stated the current proposals are the most drastic changes they have seen since the inception of Medicare** LEARN HOW TO DEAL WITH THE RETURN OF RAC AUDITS GETTING ON BOARD WITH E-PRESCRIBING AND QUALITY REPORTING TO AVOID PENALTIES GUIDELINES FOR RED FLAG TO ENSURE COMPLIANCE WITH CURRENT POLICIES NEW CPT AND ICD DOCUMENTATION REQUIREMENTS CODING FOR CARDIOLOGY PROCEDURES AND LEGITIMATELY MAXIMIZING REIMBURSEMENT ______________________________________________________________________________ UPDATE OF LCDs - JULY 2009 Local coverage determination (LCD) statuses LCD status indicators A = Active policy; notice period complete and the policy is in effect C = Draft LCD released for comment D = Draft under development; not yet released for comments E = Formal comment period has ended; comments now being considered F = Final new/revised LCD has been issued for notice Date updated Medicare Coverage Database ID number Description Comment period Current status Final LCD release date 06/30/09 L29412 Cardiovascular Stress Testing 02/20/09-04/06/09 A 04/23/09 05/29/09 DL29132 Destruction of Paravertebral Facet Joint Nerve(s) 06/01/09-07/15/09 C   05/29/09 DL29256 Endoscopic and Percutaneous Lysis of Epidural Adhesions 06/01/09-07/15/09 C   06/30/09 L29168 Erythropoiesis Stimulating Agents 02/20/09-04/06/09 A 04/23/09 06/30/09 L29195 Independent Diagnostic Testing Facility 02/20/09-04/06/09 A 04/23/09 05/29/09 DL29200 Intensity Modulated Radiation Therapy (IMRT) 06/01/09-07/15/09 C   06/30/09 L29959 Intravitreal Bevacizumab (Avastin®) 02/20/09-04/06/09 A 04/23/09 06/30/09 L29953 Non-Emergency Ground Ambulance Services 02/20/09-04/06/09 A 04/23/09 05/29/09 DL30351 Pharmacological Medication Management for Psychotherapy Services 06/01/09-07/15/09 C   06/30/09 L29949 Polysomnography and Sleet Testing 02/20/09-04/06/09 A 04/23/09 06/30/09 L29941 Renal Angiography 02/20/09-04/06/09 A 04/23/09 06/30/09 L29476 Scanning Computerized Ophthalmic Diagnostic Imaging 02/20/09-04/06/09 A 04/23/09 06/30/09 L29328 Screening and Diagnostic Mammography 02/20/09-04/06/09 A 04/23/09 06/30/09 L29414 Sinus X-ray(s) 02/20/09-04/06/09 A 04/23/09 06/30/09 L29279 Skin Substitutes 02/20/09-04/06/09 A 04/23/09 05/29/09 DL30366 Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) 06/01/09-07/15/09 C   06/30/09 L29288 The List of Medicare Noncovered Services 02/20/09-04/06/09 A 04/23/09 05/29/09 DL30353 Ultrasound of Spine 06/01/09-07/15/09 C   05/29/09 DL29128 Wound Debridement Services 06/01/09-07/15/09 C