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Medicare FFS & 5010

October 21, 2013

So another new year and another delay in Medicare Part B adjudicating fee-for-service (FFS) claims. In fact, to make your life easier Medicare Part B will once again hold your claims for ten days to allow the US Congress to pass a “pay fix;” (see December 19, 2012 CMS Message 201112-39). Only in this market would we be thankful for a 1% raise but ONLY because a 27% decrease was averted!! Smart politics but bad business. Until the SGR is permanently rectified this problem continues ad nauseum.

Thankfully as a CHC, the impact is minimal in terms of actual payment. Certainly inpatient hospital, outpatient diagnostics (TC only), and carved out specialists will see a hit but encounter rate (Medicare Part A) compensation goes full steam ahead with a guaranteed increase… no congressional intervention necessary.  Only other snag are those pesky commercial payers who could implement a decrease in payment if they pay based on a percentage of the Medicare fee schedule but only use the schedule BEFORE the correction. Watch for this!

Now the only other challenge will be assuring 5010 compliance… BUT WAIT, perhaps you or one of your team saw a “Part B News” article discussing the delay of penalty imposition until the start of 2Q12 (i.e., April 1, 2012).  Don’t be fooled into thinking you can delay implementation at your CHC.  A number of payers already mandate 5010-compliance and even though government penalties might not hit until April, wouldn’t claim denials due to lack of 5010 formatting be penalty enough???

Avoid the madness and be 5010 compliant, ASAP. By now you should have cleared things with your practice management software vendor, your clearinghouse, and for the few CHCs submitting directly to any third party payers… you guys need to also verify that your claim files are meeting all 5010 standards.

 Happy Holidays and good luck in 2012.

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