Medicare Rates for Medicaid Services

The Affordable Care Act contains a wide variety of initiatives which influence the practice of medicine. Among those is the looming expansion of the Medicaid program. By raising the eligibility threshold to 133% of the federal poverty line, the Congressional Budget Office anticipates an additional 17 million individuals will be eligible for Medicaid in 2016.  A significant concern is provider availability. It’s no secret that Medicaid reimbursement is substantially lower than for every other payer. In fact most states reimburse physicians well below Medicare rates. In economic terms one might imagine an impending supply and demand crisis. The ACA is ramping up demand for services by increasing the Medicaid patient population while at the same time the supply of physicians prepared to care for this population is shrinking.

 

This piece of legislation is remarkably complex, however; and buried within the ACA is a solution recently brought to my attention by Pam Hobbs. Pam works in the Fresenius Physician Practice Services group as the VP of Practice Operations for the state of Utah. Published in the November 6, 2012 Federal Register is a final rule with the inauspicious title “Medicaid Program; Payments for Services Furnished by Certain Primary Care Physicians and Charges for Vaccine Administration Under the Vaccines for Children Program”. Ignoring childhood immunizations for the moment, this special payment provision is likely to be of interest to a large number of nephrologists.

 

This special payment provision effectively uses federal dollars to bring Medicaid rates up to Medicare rates for a wide variety of services. Of equal importance is the fact that the services covered by this rule are remarkably broad. Some of the specifics include:

1. The definition of “primary care physician” is expansive and includes physicians who self-attest to a specialty designation of family medicine, general internal medicine, pediatric medicine, or a subspecialty within those specialties recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS) or the American Osteopathic Association (AOA). This includes nephrologists as well as many other medical subspecialists.  Alternatively, physicians can meet the primary care definition by self-attesting that they have furnished applicable evaluation and management services and vaccine administration services that equal at least 60 percent of the Medicaid codes they have billed during the most recently completed calendar year, or, for newly eligible physicians, the prior month.
2. The services covered by the rule are very broad and include Healthcare Common Procedure Coding System (HCPCS) codes 99201 through 99499. Note this group of codes includes not only the commonly used office based E & M codes, but also E&M codes in the hospital, skilled nursing facility, and home settings.

Many of you may already be aware of this special payment provision. For those who are not, you may wish to explore this at the local level. I might suggest an internet search along the lines of “(your state) Medicaid and primary care physicians”. In my home state this quickly led to a link to the State Medical Society’s guidance on enrollment. Each state may handle this differently, but the rule requires the provider to attest that he/she is either board certified with one of the specialties or subspecialties mentioned above, or that over a predefined time interval at least 60% of the services rendered to Medicaid beneficiaries by the provider consisted of the primary care and vaccine administration services covered by this rule. The attestation process is time sensitive. In my home state, the attestation process must be complete on or before March 31, 2013 in order to receive the Medicare rates for services rendered on or after January 1, 2013. These dates may vary in your state. Finally, the rule includes services rendered during calendar years 2013 and 2014. I suspect we will see additional opportunities in the years ahead.

 

In summary, the ACA has created an opportunity to bring Medicaid rates in line with Medicare rates for many of the services rendered by nephrologists. In order to benefit from this special payment provision, you must confirm your eligibility by attesting with your state’s Medicaid program. The attestation specifics will vary slightly among states, but in many cases it simply requires completing a one page form, signing it and faxing it to your State’s Medicaid office. CMS recently published a list of frequently asked questions regarding this special payment provision. Given the time sensitive nature of this matter, the sooner you take action the better.