MPPR is a per-day policy that applies across disciplines and across settings. For example, if an SLP and a physical therapist both provide treatment to the same patient on the same day, the MPPR applies to all codes billed that day, regardless of discipline. Under MPPR, full payment is made for the therapy service or unit with the highest practice expense value (MPFS reimbursement rates are based on professional work, practice expense, and malpractice components) and payment reductions will apply for any other therapy performed on the same day. For the additional procedures provided on the same day, the practice expense (i.e., support personnel time, supplies, equipment, and indirect costs) of each fee will be reduced by 50% (effective April 1, 2013) for Part B services in all settings. The professional work and malpractice expense components of the payment will not be affected. ASHA has developed three MPPR scenarios to illustrate how reductions are calculated.
Aetna to cut pathology reimbursement to 45
In 2011, Medicare paid between 18 and 30 percent more than other insurers for 20 high-volume and/or high-expenditure lab tests. Medicare could have saved $910 million, or 38 percent, on these lab tests if it had paid providers at the lowest established rate in each geographic area. State Medicaid programs and 83 percent of FEHB plans use the Medicare CLFS as a basis for establishing their own fee schedules and payment rates, although most pay less. However, unlike Medicare, FEHB programs incorporate factors such as competitor information, changes in technology used in performing lab tests, and provider requests in their payment rates. Some State Medicaid programs and FEHB plans required copayments for lab tests, which, in effect, lowered the costs of lab tests for the insurer.
How Medicare, Other Payers Determine Physician Reimbursement Rates
Do you know how Medicare and other payers determine reimbursement rates? Most physicians don’t. Reading this summary of the history and elements will take less than three minutes, and will make you better informed than most. History. The resource-based relative value scale (RBRVS) was introduced in the Omnibus Budget Reconciliation Act of 1989. The intent was to create a uniform and objective payment system to address the large payment disparities produced under the traditional usual, customary, and reasonable (UCR) standard. The new scheme was adopted over a five-year transition period. NOTE: The sustainable growth rate (SGR) was part of the Balanced Budget Act of 1997 and is separate. Relative Value Units (RVUs) and CPT codes. Three RVUs are assigned to each CPT code: Physician work RVU: A relative measure of the time, skill, training, and intensity required to provide a specific service The goal is for each CPT code to be reviewed at least every five years in order to make adjustments to reflect changes in the components of the service. Practice expense RVU: Addresses expenses associated with providing the service. The direct costs (staff allocation, supplies, and equipment) of the service are calculated; indirect costs (any costs of operations not directly involved in providing the service) are allocated. A new method of calculating practice expense was fully implemented in 2010, after a transition period. Malpractice RVU: Costs associated with professional liability expenses. Who sets RVUs? CMS sets RVUs based upon the recommendations of the Specialty Society Relative Value Scale Update Committee (RUC). The RUC is made up of 29 physicians, 23 of whom are nominated by professional societies. Almost all are specialists. CMS is not bound to accept either the professional society nominees or the RUC’s recommendations, but it has historically approved more than 90 percent of RUC recommendations. The process has been criticized for a lack of transparency. There are also those who argue for more representation by primary-care providers, private insurers, and employee health plan purchasers. Geographic Practice Cost Indices (GPCI). A GPCI is calculated, by CMS, for each of the RVU components. The GPCIs are reviewed every three years and attempt to take into account the different costs associated with different areas of the country. Conversion Factor (CF). The CF translates RVUs and GPCIs into actual dollars. It is updated annually according to a formula specified by statute. CMS may not, by statute, increase its total annual budget by more than $20 million. If shifts in the RVUs would increase CMS’ budget by more than $20 million, the CF is used to achieve, essentially, budget neutrality. Congress may override the CF formula and regularly does. Non-Facility Payment Amount. A non-facility is a freestanding physician’s office, as well as other freestanding settings. Inpatient facilities, hospital outpatient clinic settings, and off-site hospital-owned locations are considered “facilities.” The payment for each CPT code in a non-facility is calculated as follows: Payment = [(Physician Work RVU X Work GPCI) + (Non-Facility Practice Expense RVU X Practice Expense GPCI) + (Malpractice RVU X Malpractice GPCI)] X (Conversion Factor, adjusted for budget neutrality) 2014 Payment Changes. CMS released the finalized payment rates and policies for 2014 on Nov. 27, 2013. The total payments under the fee schedule are projected to be $87 billion. The largest increases go to psychiatry, clinical psychologists, and clinical social workers, as well as other providers of mental health services. There was also an aggregate increase in physician work RVUs and a corresponding decline in practice expense RVUs. Beginning in 2015, CMS will establish separate payments for managing a patient’s care outside of face-to-face contact. Private Payer Reimbursement. Most, if not all, private payers tie their reimbursement rates to Medicare’s. Contrary to widespread perception, private payers often reimburse at rates lower than Medicare. As intricate as this may seen, these are just the basics. Bonuses and penalties for quality, patient satisfaction, eRX, and meaningful use are topics for another day.
CMS Announces New Medicare Reimbursement Rates for 2014
The proposed rule would increase IPPS operating rates by 0.8 percent after accounting for inflation and other adjustments required by the law. This proposed increase also reflects a proposed temporary reduction of 0.8 percent to implement the American Taxpayer Relief Act’s requirement to recoup overpayments from prior years as a result of a new patient classification system that better recognizes patient severity of illness. CMS is also proposing an additional 0.2 percent reduction to offset projected spending increases associated with proposals regarding admission and medical review criteria for inpatient services. CMS projects that LTCH PPS payments would increase by 1.1 percent, or approximately $62 million, in FY 2014.
Medicare Coverage of Speech
This area of the Reimbursement site provides information on the major aspects of Medicare related to audiology and speech-language pathology services, including Medicare coverage guidelines and reimbursement rates.