The PLTC Public Policy Committee is following Medicare Policy changes for Medicare Carriers that the majority of PLTC Members practice under. Updates to LCD's for the following carriers will be updated and posted to the Medicare Carrier Update page (Available to PLTC Members only; update January 2008): Palmetto GBA, Noridian, Trailblazers, National Heritage, Empire, Highmark, First Coast, Wisconsin Physician Services.
RESOURCE: Medicare Handbook - A Guide for Psychologists, published in 2002 by APA Practice.
(Available ONLINE)
Also visit the 12-2 (Clinical Geropsychology) Website on Medicare News
List of All Part B Carriers By State (opens in MS Word Format)
February 14, 2008--The APA Practice Organization's (APAPO) top legislative priorities for 2008 involve confronting Medicare payment problems facing psychologists and achieving mental health parity in private sector insurance coverage. Members have asked us for regular updates on what we are doing to pursue these priorities.
This article summarizes briefly several related issues the APAPO is addressing and the actions we are taking on behalf of professional psychology.
The Issue: A 10.1 percent Medicare payment cut was originally scheduled to take effect at the beginning of 2008. At the behest of APAPO and other health professional societies, Congress acted in December 2007 to avert the cut for January 1. However, the legislative action simply delays the scheduled cut for six months - until July 1, 2008.
APAPO Action: The APAPO is lobbying Congress to make permanent the delay in this Medicare cut and avert further payment reductions for 2009.
The Issue: Despite the delay in the 10.1 percent Medicare cut, many practitioners still face lower Medicare reimbursements in 2008 compared to 2007. There are a number of reasons involved. One factor is that in 2007 the Centers for Medicare and Medicaid Services (CMS) began using a new methodology to determine values for the "practice expense" component of Medicare reimbursement. Some services, such as diagnostic interview, now have higher practice expense rates. But practice expense rates for other services that psychologists commonly bill, including the 45- and 75-minute psychotherapy codes, were lowered. (The change in methodology for calculating practice expenses was applied to all Medicare services, not just behavioral health.)
APAPO Action: We believe that many practice expenses are undervalued by the new CMS methodology. The APAPO is taking part in a large, multidisciplinary survey organized by the American Medical Association in order to provide CMS with new practice expense data that we believe more accurately reflects the cost of running a psychology practice.
The Issue: In 2006, CMS released the results of a five-year review of Medicare services. Because of changes that resulted from this review, psychologists and other health professionals experienced substantial payment cuts that took effect January 1, 2007.
APAPO Action: We have lobbied members of the House and Senate extensively on this issue and continue to do so. Last year, APAPO mobilized our grassroots-psychologist constituents who sent more than 18,000 emails to legislators demanding that funds be restored. The House passed a provision in 2007 that would raise reimbursements for psychotherapy services by $30 million a year for four years. APAPO is urging senators on the Senate Finance Committee to support similar legislation when that committee of jurisdiction takes action this spring.
The Issue: In November 2006, CMS finalized a proposal to increase Medicare payments for "evaluation and management" (E&M) services effective January 1, 2007. However, psychologists are not eligible to bill using the E&M codes.
APAPO Action: E&M services include functions such as establishing diagnosis and treatment options and coordinating care. As psychologists are well qualified to provide an array of E&M services, we are advocating with both CMS and Congress to make psychologists eligible to provide E&M services. This activity includes ongoing dialogue with Senator Jeff Bingaman's (D-N.M.) office to include psychologist E&M eligibility language in the Senate Finance Committee's Medicare bill (see the preceding 'action').
The Issue: Last September, the Senate passed a mental health insurance parity bill that would extend full parity protections to 113 million Americans. The issue is now before the House.
APAPO Action: APAPO strongly supports the Senate bill that passed last September, having engaged in a year-long effort to secure backing for that bill from employer and insurer organizations. Our negotiations greatly lessened the chance that traditional opponents would block the legislation. APAPO is seeking passage of the House version in an effort to move the bill to House-Senate negotiations for final passage this year.
CMS AWARDS TWO CONTRACTS TO PROCESS AND PAY MEDICARE PART A AND PART B CLAIMS IN 7 STATES AND D.C.
The Centers for Medicare & Medicaid Services (CMS) today announced that it has awarded two contracts for the combined administration of Part A and Part B Medicare claims payment in seven states, the District of Columbia and three U.S. territories.
These awards represent the fourth and fifth new Medicare Administrative Contractors (MACs) to be named by CMS as required by the Medicare Modernization Act of 2003. The MAC contracts are part of an effort to streamline the fee-for-service payment system. The two contracts announced today are among the largest, in terms of claims volume, of the 15 MACs that CMS will award.
Highmark Medicare Services Inc., headquartered in Camp Hill, Pa., will be responsible for Jurisdiction 12, which includes the states of Delaware, Maryland, New Jersey and Pennsylvania, as well as the District of Columbia. Palmetto GBA, headquartered in Columbia, S.C., will serve Jurisdiction 1, which includes California, Hawaii, Nevada, American Samoa, Guam and the Northern Mariana Islands. By 2011, a total of 15 new MACs will cover every state and the District of Columbia. The first three MACs are processing Medicare claims in 10 western and four midwestern states.
The MACs will serve as the primary point of contact for the processing and payment of fee-for-service claims from providers, such as hospitals, nursing facilities, physicians and other practitioners. The MACs were selected in open competition under federal procurement rules.
As MAC contractors, Highmark Medicare Services and Palmetto GBA will immediately begin implementation activities. Highmark Medicare Services will assume full responsibility for the claims processing work in its jurisdiction no later than September 2008. Palmetto GBA will assume full responsibility for the work in its jurisdiction no later than June 2008.
CMS awarded the first MAC contract in July 2006 to Noridian Administrative Services, LLC, headquartered in Fargo, N.D. Noridian covers the states of Arizona, Montana, North Dakota, South Dakota, Utah and Wyoming. The second contract was awarded on Aug. 3, 2007, to TrailBlazer Health Enterprises, headquartered in Richardson, Texas. TrailBlazer will cover Colorado, New Mexico, Oklahoma and Texas. The third contract was awarded on Sept. 4, 2007, to Wisconsin Physicians Health Insurance Corp., headquartered in Madison, Wis., which will cover Iowa, Kansas, Missouri and Nebraska. CMS expects to award three more MAC contracts by the end of the year.
For more information, see http://www.cms.hhs.gov/MedicareContractingReform/
J4 MAC (Texas, Colorado, New Mexico, Oklahoma) Listservs
TrailBlazer encourages providers to register for the J4 MAC Implementation News listserv as well as the state-specific listserv for their service area from the J4 MAC Web site at http://www.trailblazerhealth.com/j4. By registering for these listservs, providers will receive the latest information on J4 MAC implementation activities and all new process updates or changes. Jurisdiction-wide information will be shared in the J4 MAC Implementation News listserv as often as is needed, with state-specific information included in the state-specific listservs.
NPI Information
Please visit the new CMS Web page dedicated to providing all the latest National Provider Identifier (NPI) news for health care providers. Click on this link for more information.
UPDATE
It has recently come to CMS' attention that there are incorrectly formatted versions of the revised claim form being sold by print vendors. Therefore, CMS has decided to extend the acceptance period of the Form CMS-1500 (12-90) version claim which are received, regardless of the date of service, beyond the original April 1, 2007 deadline while this situation is resolved. Providers that are required to continue submitting the Form CMS-1500 (12-90) will only be required to provide their legacy provider numbers, as the Form CMS-1500 (12-90) cannot accommodate the NPI. It is important to note that this issue involves the paper claim form only, not the electronic transaction which can accommodate the NPI. In addition, this situation does not affect the current NPI implementation date of May 23, 2007.
CMS has issued a Change Request (CR) 5204. The CR can be viewed by using this link. The CR clarifies coding guidelines for psychological and neuropsychological testing:
1) One time-based code should reflect the time spent to provide the service. Use of multiple time-based codes, in aggregate, is not appropriate;
2) Medicare does not authorize payment for psychological and neuropsychological testing when performed on an incident-to basis;
3) Psychological/neuropsychological testing codes should not be reported by the treating physician for only reading the results of the testing. The reading of the report is included in the office or floor time in the hospital and would be included in the evaluation and management service for that day;
4) Psychological test code 96101 should not be billed for the same test or service performed under codes 96102 or 96103. Neuropsychological test code 96118 should not be billed for the same test or service performed under codes 96119 or 96120;
5) Codes 96101, 96105, 96116 and 96118 are time-based codes and should be billed with units of service that reflect the total hours spent administering, interpreting and reporting the test. If the performance, interpretation and reporting of the testing spans more than one day, then the entire service should be reported on one line of coding and billed for the date of the final report;
6) Codes 96102 and 96119 are time-based codes and should be billed with units of service that reflect the total hours spent face-to-face with the patient, administering the test. For example, if a technician spends two hours administering a psychological test, and the psychiatrist performs the interpretation and report, then the psychiatrist should bill two units for code 96102, for the date the test was administered;
7) Codes 96103, 96110, 96111 and 96120 are not time-based codes and cannot be multiple serviced. They should be billed for the date the test was administered;
8) Non-Physician Practitioners (NPPs), such as NPs, CNSs, and PAs, who personally perform diagnostic psychological and neuropsychological tests are excluded from having to perform these tests under the general supervision of a physician or a CP;
9) Independently practicing psychologists (IPPs) may bill for psychological and neuropsychological tests when the test is ordered by a physician.
Message from Russ Newman at APA re: Medicare Cuts
Yesterday the Centers for Medicare and Medicaid Services (CMS), the federal agency that runs the Medicare program, released the final 2007 physician fee schedule rule. This final rule contains both the 5% sustainable growth rate (SGR) cut and a 9% cut in psychologist reimbursement associated with the 5-year review rule initially proposed on June 29th.
The 5% SGR cut is required by statute to contain the rate of Medicare cost increases, and as you know, we have successfully fought back this cut in years past. The 9% 5-year review cut is associated with CMS's increase of payments for evaluation and management services. Under Medicare law, when CMS increases payments for certain Medicare services, it must decrease payments for other services to maintain budget neutrality, and in this instance, CMS has provided an across-the-board cut to a part of the payment formula for all provider services. While it is of little comfort, all Medicare providers are facing these cuts to a varying degree.
With your support and the support of many of our members, we have been fighting to prevent these cuts, particularly the 9% 5-year review reduction. Specifically, we have met with many members of key Congressional committees to assist us in this effort. In addition, I am calling on the Speaker of the House of Representatives and the Senate Majority Leader to avert these cuts due to their impact on our provider reimbursement rates and on Medicare patient access to the services that we provide.
Unfortunately, with the upcoming elections, we simply do not know if we will be able to attain a resolution before Congress adjourns before the end of the year. It is possible that Congress will not address this issue this year and the cuts will occur in January. We are working for any opportunity this year, but if Congress does not act we will seek a resolution early next year. Our experience is that such a resolution will likely include a retroactive adjustment to payments if the cut is implemented in January.
Please contact Marilyn Richmond or Doug Walter of our government relations office at (202) 336-5889, with your comments or questions.
Sincerely,
Russ Newman Executive Director for Professional Practice Practice Organization
Medicare Announces Final Rule Setting Physician Payment Rates and Policies for 2007
New Payment Rates will encourage increased physician/patient communication: Starting next year, the Medicare program will pay physicians more for the time they spend talking with Medicare beneficiaries about their health care and will pay for a broader range of preventive services. The changes, which will become effective January 1, 2007, are included in the Medicare Physician Fee Schedule (MPFS) final rule released today by the Centers for Medicare & Medicaid Services (CMS).
CMS projects that it will pay approximately $61.5 billion to over 900,000 physicians and other health care professionals in 2007 as a result of the payment rates and policies adopted in this rule. This new spending figure reflects current law requirements to reduce payment by 5 percent to account for the combined growth in volume and intensity of physician services.
"The rule we are announcing today will pay physicians more for the time they spend talking with their patients about their health care," said Leslie V. Norwalk, CMS Acting Administrator. "We believe that this emphasis on personalized care will lead to better outcomes for patients, and more efficient use of health care resources."
To view the entire press release, please click here
Medicare & You 2007 Handbook Now Available Online
The general "Medicare & You 2007" handbook is now available at this website to help people with Medicare review their coverage options and prepare to enroll in a new plan if they choose. This official government handbook contains important information about what’s new, health plans, prescription drug plans, and rights for people with Medicare. You can find 48 geographic-specific versions of the handbook on the website listed below, with drug and health plan comparison charts for particular states or regions. These are the versions that will be mailed to people with Medicare in the next few weeks.
The Centers for Medicare & Medicaid Services is encouraging people with Medicare to review their current coverage this fall to see if it will meet their needs in 2007. Now is the time to help people think about the cost, coverage, and customer service that they need in a plan to get the most out of their Medicare.
The state specific books are online at this website. Beneficiaries will receive their Handbooks by the end of October.
CMS Proposes Policy, Payment Changes for Physicians' Services in 2007
The Centers for Medicare & Medicaid Services (CMS) projects that it will pay approximately $61.5 billion to 875,000 physicians and other health care professionals in 2007, under a proposed rule released today that would revise payment rates and policies under the Medicare Physician Fee Schedule. These proposals are in addition to the proposed revisions to the work relative value units (RVUs) and proposed changes in the methodology for calculating practice expense RVUs released in a separate proposed notice in the June 29 Federal Register.
To view the entire press release, please click here (opens in a new window).
Planned Release of a Request for Information (RFI) Concerning the Scope of Work and Specialty Activities that CMS Will Include in the Next Medicare Administrative Contractor (MAC) Procurements
 |
CMS announced on July 31, 2006 the awarding of the first of 15 contracts for the combined administration of Part A and Part B claims activities in a multi-state jurisdiction. That first Medicare Administrative Contractor (MAC) award was for the 6-state jurisdiction of Arizona, Montana, North Dakota, South Dakota, Utah and Wyoming (Jurisdiction 3). | ||||||||
|
CMS has 14 more Part A/Part B MAC contracts to acquire through the competitive process. These procurements will be conducted in two cycles. Cycle One of the A/B MAC acquisitions will be for 7 jurisdictions, accounting for approximately 45 percent of the Part A/Part B fee-for-service claims workload. CMS will conduct these 7 competitions in two rounds. | ||||||||
|
The first round of competitions under Cycle One will cover 3 jurisdictions
| ||||||||
|
The Request for Proposal for this first round of competitions under Cycle One will include mandatory options for the following specialty activities
| ||||||||
|
On Wednesday, August 9, 2006 CMS will publish on the Federal Business Opportunities website (www.FedBizOpps.gov) a Request for Information (RFI) containing the planned SOW for the second round of competitions under Cycle One. Public comments will be due on Thursday, August 31. CMS encourages everyone to review the RFI and provide comments or questions. You will find guidance on how/where to submit comments and questions about the RFI on that same FedBizOpps site. | ||||||||
|
The second round of competitions under Cycle One will include the remaining jurisdictions
| ||||||||
|
The RFP for this second round of competition will include the following mandatory options
| ||||||||
|
To learn more about the transition to the A/B MAC environment, please visit the Medicare Contracting Reform website at http//www.cms.hhs.gov/MedicareContractingReform/. |
Medicare to Stop Mailing Standard Paper Remittance (SPR) for Those Providers/Suppliers Also Receiving the Electronic Remittance Advice (ERA)
|
Beginning June 1, 2006, the SPR received through the mail will no longer be available to providers/suppliers who also receive an ERA, whether the ERA is received directly or through a billing agent, clearing house, or other entity representing a provider/supplier. In response to the provider/supplier communities continued need for SPRs, CMS has developed free software call Medicare Remit Easy Print (MREP) that gives providers/suppliers a tool to read and print a remittance advice (RA) from the HIPAA compliant Health Care Claim Payment/Advice (835) file. The MREP software was designed to incorporate new functionality to save providers/suppliers time and money. The paper output generated by MREP is similar to the SPR format. The CMS has worked with other payers to insure their acceptance of the SPR generated by the MREP software for Coordination of Benefit claim submission. Additionally, CMS has worked with clearinghouses to assure similar software is available to read and print an ERA for those providers/suppliers that utilize clearinghouse services. We encourage providers/suppliers currently receiving the ERA, who don’t use software to read and print RAs from these files, to begin using MREP or other similar software before the June 1st cutoff. Please go to this website for further information regarding MREP software. We appreciate your continued cooperation as the Medicare program moves toward a more electronic environment. |
2006 Revised CPT Testing Codes An Update From the APA Practice Directorate
| The revised CPT codes for psychological and neuropsychological testing will go into effect on Jan. 1, 2006. As part of the Practice Directorate's ongoing efforts to help practitioners be knowledgeable about and make the best use of the revised codes, this article provides answers to recent questions from practitioners about changes to the codes. Login to APApractice.org to read more. |
Summary of 2006 changes in the Medicare appeals process from the Medicare Rights Center
"Starting January 1, if Medicare denies your first appeal, you can request a "reconsideration" (replacing the Part B "fair hearing"). You will have six months (180 days) to file after Medicare denies your initial appeal. This second level of appeal will be handled by a new group of Medicare contractors called Qualified Independent Contractors (QICs), who will review your medical file to determine if the service in question should be covered. You will not appear in person for the reconsideration.
If the QIC denies coverage, you can continue to appeal through another three levels of review:
You should also be aware of two other important changes to the Medicare appeals process:
| Medicare will only send initial determinations of coverage-in the form of a Medicare Summary Notice (MSN)-to the person with Medicare even when Medicare knows that the person has an appointed representative. If you are the appointed representative for someone with Medicare, make sure you are checking the person's mail for the MSNs. |
| Written notices of appeals decisions must explain how the decision was made; how to request the next level of appeal; and what documents you should submit. |
Want to know more about the new Medicare appeals process? Visit the Center for Medicare Advocacy for a detailed overview of the changes.
Need a Medicare appeals form? Log on to Medicare.gov to find various downloadable forms to appoint a representative or request a review."
March, 2005
| AHCA names states to be hardest hit by 2006 budget cuts. The American Health Care Association further blasted the proposed Medicare and Medicaid funding cuts Wednesday, naming the 10 states in which providers and the elderly would be most negatively impacted. Nursing homes and the elderly in the New York, California, Texas, Florida, Pennsylvania, Ohio, Illinois, North Carolina, Massachusetts and New Jersey would be the hardest hit, based on AHCA analysis of cumulative cuts. The cuts would take a projected $7.4 billion and $5.6 billion from New York and California, respectively, alone over the next 10 years, the association said. |
|
Medical Necessity -- As Defined by Trailblazer (D.C. Metro/Delaware, Maryland, Texas, Virginia) |
| Decision Summary for Smoking and Tobacco Use Cessation Counseling |
| House and Senate pass contradictory Medicaid budget items Medicaid cuts got a "thumbs up" in the House but a "thumbs down" in the Senate Thursday as the two legislative bodies passed somewhat opposing budget items. While the House approved a budget resolution that would slash $20 billion from Medicaid over five years, the Senate voted for an amendment that would remove $14 billion in cuts from its 2006 budget resolution. Both votes were close. The House voted 218-214 in favor of its budget resolution. The Senate voted 52-48 for its amendment. The Senate is not expected to pass its budget until April. Provider organizations on Thursday hailed the Senate¹s passage of the amendment, which calls for replacing $14 billion in cuts with a Bipartisan Medicaid Commission to analyze Medicaid. Sen. Gordon Smith (R-OR), who is chairman of the Senate Special Committee on Aging, and Jeff Bingaman (D-NM), brought the amendment to the Senate floor this week. |
February, 2005
| Medicare ruling regarding protection of psychotherapy notes |
