Late last night, Congress passed the latest delay in the implementation of the 21.3% pay cut to the Medicare physician fee schedule. Unfortunately, the legislation was only acted upon urgently when CMS stated that by law they had no other option but to begin to process Part B claims for dates of service of April 1st and after with the pay cut beginning yesterday.

CMS will now instruct the contractors to reprocess all claims for services rendered after April 1st  that were processed on April 15th. This basically means that if you receive a Medicare explanation of benefits (EOMB) that is dated 4/15/2010, and the payments on charges reflect the cut, you should receive an EOMB from a subsequent date with the additional payment for these same charges.

This latest fix will be in effect until May 31st, 2010.  

We are now 3 1/2 months through the year, and a permanent fix to the Sustainable Growth Rate (SGR) formula has yet to be acted upon. There are only two visions of Congress running through my head when I think about this topic. The first has to do with the yellow-fingered denizens of a heroin shooting gallery craving their next balloon, and the second is that episode of the Three Stooges where they attempt to fix someone’s plumbing. Either one on its own is either horrifying or funny, but when blended together quickly becomes the nightmare scenario in which we now exist on a month-to-month basis.

I can clearly and unabashedly state that based on how American tax dollars were spent from 2001 through 2009, clearly legislative and budgetary ignorance are not particularly virtues of any one political party. Yet as the SGR rock is continually booted down an ever-darkening path as the sun sets on common sense, doctors and an ever-expanding Medicare population now walk a knife-edge, with physicians crunching future numbers wondering how to stay in the business of health care and elderly and infirmed patients wondering if they’ll be able to see a doctor at all.

In the last ten years, through either epic overreaching or near-criminal inaction, our government has either directly or indirectly broken budget surpluses, civil liberties, our court system, the ease of air travel, banking, housing, manufacturing, civil discourse, a bridge in Minneapolis, two buildings in New York City, Iraq, Afghanistan and the city of New Orleans.  Is it too much to ask that just one thing that directly affects the general welfare of a significant portion of our population gets fixed?

Last night, my family and I became the proud owners of a shelter cat. He’s a (roughly) 8-year-old tabby named Mike. In the 12+ hours we’ve owned him, my first instinct is to change his name to Elmer, as this cat is glued to any human that enters the room. He has already gotten very comfortable with head-butting my arm as I try to operate a mouse on my home office desk. I also learned very quickly this morning that eating and checking e-mail to start my day may require three arms from this day forward.

There is one very clear ill effect thus far to this sudden change in my home population, and that would be the effect Mike is having on Rocky, the family dog. Rocky is very much my wife’s protector, and visual contact with her must be maintained at all times. When this isn’t maintained, Rocky begins to shake, whine and pace back and forth. To introduce Mike to the home, we’re starting him out in one room of the house. When my wife disappears into that room, closing the door behind her, Rocky takes this behavior to a new and as-yet undiscovered height. It was hard for me to believe this morning that this squealing and cowering nervous wreck is the same dog who boldly and aggressively barks at the mailman every day.

For both human and canine, sudden and abrupt change can be a time of upset and discomfort. In the health care arena, as the dust settles in the days and weeks after the passage of the Patient Protection and Affordable Health Care Act, we have all been internalizing information contained in the law and how it affects every facet of the health care delivery system. Knowing this, it’s important to know what the heavy hitters in the industry (namely insurance companies and doctors) have begun to  put in place to prepare for the bulk of the changes that will hit in 4 years.

In looking at the insurance industry, it is important to remember that every one of them has a team of lawyers that are more than happy to dissect any law to see how the words on the printed page can be manipulated in favor of the company and its stockholders.

The industry already gave itself a gift with the portion of the law which mandates coverage for all who can afford it. After Medicare Part D was passed in 2003, the insurance industry used Medicare drug coverage as a golden opportunity to expand its reach into the federal health insurance plan by using their drug plans as a selling point for Medicare Advantage plans. In many cases, industry practice was comparable to the long-distance telephone slamming that went on in the 1990’s, with people not realizing what product they had until the first bill came in the mail.

The new law mandates that insurance companies who offer Medicare Advantage plans must put in place provider networks for the plans by 2011. Some of the bigger insurance companies with Medicare Advantage plans have begun to answer this mandate by pulling out of the Medicare Private Fee For Service market altogether rather than going through the expense of building a provider network. It’s a calculation that ceasing coverage for a portion of the older population which tends to use medical resources more often will lead to a healthier bottom line when compared to the cost of building a provider network. With the post-World War II baby boomers beginning  to turn 65, and with average life expectancy in the mid to late seventies depending on gender, saying goodbye to such a large portion of the market would appear to be a long-term financial gamble akin to what banks did prior to the mortgage bubble bursting. In the short term, the discomfort of change will be placed upon those currently covered under a Medicare PFFS plan that terminates at the end of the year. All this time, I thought the Scorched Earth Policy officially ended with Napolean’s ill-conceived invasion of Russia. It looks like I got that one wrong.

The AMA issued a press release shortly after the passage of the law attempting to draw attention to the financial benefits to physicians. While it’s good to maintain a positive attitude in times of change, it is a good time to note that 5 days from now, without a legislative fix, Medicare payment rates will fall 21.3% for all services after April 1st. As in the past, a temporary fix is expected, yet an opinion is beginning to develop in the physician community that without a permanent fix to the Sustainable Growth Rate (SGR) formula for calculating physician payments, the world of health care delivery for the elderly American will suddenly be a narrow and unfriendly place.

Change brings anxiety. From a multi-billion insurance company to the family dog, long-held routines bring comfort and a sense of security. Due to the new reform law, the business of health care finds itself on the precipice of a pit obscured by clouds. Whether the distance below these clouds is 5 feet or 5,000, it is in the preparation for either eventuality of the leap that determines the jumper’s fate.

I bid you welcome to my day off.

At long last, my 3-year-old son, whose preschool is closed today, has settled down for a nap just long enough for me to turn my attention to this humble little corner of the world wide web. With the help of Brian Wilson’s Smile at half-volume in my mp3 player, I now ready myself to bring you the weekly update in the wacky, wonderful world of American health care. As you will see in the succeeding paragraphs, the phrase “promote the general welfare” as it appears in the U. S. Constitution has been on an odd road as of late.

In last week’s post, I spent some time going over the issues most often faced on the patient side of the health care delivery system in the health care overhaul. As we dig deeper into the Patient Protection and Affordable Healthcare Act, it appears that the provider community is about to enter a world of scrutiny and forced conversion unlike any we have seen since the dawn of the government’s role in health care.

Beginning with Medicare basics, retroactive to January 1, 2010, providers will now face a 12-month filing deadline from the date of service for claims to Medicare for reimbursement. Any dates of service prior to January 1, 2010 will need to be submitted to Medicare by December 31st of this year. Claims that do not will face timely filing denials.

As if doctors didn’t have enough to worry about in the current climate of fraud and abuse investigation, the new law has decided to put the current process on a diet of steroids and gun powder. The existing Medicaid Integrity Program appears about to either be strengthened or usurped by Recovery Audit Contractors in every state tasked with discovering overpayments and underpayments specifically from Medicaid. On the national side, the existing RAC’s will be expanding their investigations to include Medicare Advantage plans and drugs dispensed under Medicare Part D. As the RAC’s are independent contractors, and are rewarded a portion of any recovery gained as a result of investigation, it’s safe to say that providers shouldn’t expect a lot of checks for discovered underpayments in this new environment.

As if the investigations of claims wasn’t enough to give providers an Orwellian sense of paranoia, the Medicare enrollment and revalidation process is about to change in a similar manner. New providers and re-enrollees will now be subject to an enhanced screening process yet to be devised by the Department of Health & Human Services and the Office of Inspector General. It will include at least a check of the provider’s medical license. If OIG and HHS considers a particular provider to be an increased risk to the program, the provider could be subject to fingerprinting, criminal background checks and unannounced visits to the provider’s site of service.

When it comes to overpayments, any overpayment from Medicare discovered by the provider or their billing entity must now be returned to  Medicare within 60 days.

It’s a good time to take a step back and review the current landscape. In the next 5 years, interoperable electronic medical records, ICD-10, e-prescribing and quality reporting will slowly become mandatory for all medical professionals. If as a provider you have yet to explore any of these issues, now would be almost be too late of a time to start. As for myself, in order to have the physical and mental energy to deal with all of this in an advisory capacity, I’m going to take Brian Wilson’s advice; I’m gonna chow down my vegetables.