Physician Payments: Medicare, Other Payers and Recent Changes

1. Physician Payments: Medicare, Other Payers and Recent Changes Coping with Regulatory and Payer Demands to Practice PM&R Bruce M. Gans, MD

2. It is not getting any easier to practice or get paid for your work • Payers are seeking ways to avoid payment, shift responsibility, and minimize their exposure to all providers, including physicians

3. How to Increase the Chances of Getting Paid • Do the right things clinically • Document them well • Code accurately and completely • Inform the patient of their liability for paying for your services before you provide them • Collect co-pays at the time and site of service when possible • Review your insurance plan participation regularly • Review your collections regularly • Understand your contractual allowance rates

4. How to keep what you were paid • Audit your records yourself for documentation and coding accuracy • Cross-audit your charts with other providers • Engage external auditors to review, critique, and educate yourself and your staff

5. How to recover what was taken away after you were paid • Appeal everything • Follow the rules meticulously • Engage professional help • Track your success • Learn from your mistakes or failures to win

6. Working with Institutions • Medical Administrative Roles • Employment • Independent Contractor • On-call arrangements • Risks to be avoided • Review the contract carefully • Document your work if you must invoice for payment • Do the work you invoice for • Make sure your payment rate is truly fair market value

7. Working with Institutions (continued) • Clinical Roles • Incorporating Medicare documentation requirements for inpatient rehab care into your practice • Separating or commingling administrative and clinical services • Gym rounds • Team meetings with patients • Use of extenders

8. Overarching Needs • Patients come first • Balance your obligation to your patient with the responsibility to show reasonable restraint in how you provide care and authorize/prescribe drugs, goods and services • Work in close alignment with others involved in the care of your patients • You are looked to as a leader, so lead with wisdom, grace and integrity

9. Medicare Audit and Appeals Developments Peter W. Thomas

10. Update on new RAC contracts and future audits • Existing RACs continue to audit certain claims • RAC legal challenge delays awards of new round of RACs • Changes to RAC contracts that benefit providers

11. Physician-specific ADR limits • Additional Documentation Request limits by provider group

12. “Related” claims linking physician and facility claims for payment • New authority for CMS contractors to deny related claims • Specific rules governing denial of related claims

13. Two-Year ALJ hearing assignment delay and response from/impact on providers • Extent of ALJ hearing backlog • AHA Lawsuit to challenge ALJ delay • FAIR Fund Amicus brief to demonstrate harm to providers • 68% Settlement offer for acute care hospitals re: short day stays • Impact of developments on appeals process • Pointers on challenging denials of claims, including recoupment and interest

14. Congressional developments involving reforms to lessen impact on legitimate providers • Series of Congressional hearings exposing burden on providers • GAO Report on Medicare Audit Contractors • Senate Special Committee on Aging Report on Audits and Appeals • Pending legislative efforts on Medicare audits and appeals

15. Physician-specific Considerations involving Medicare Claims

16. Physician documentation of prosthetic/orthotic claims • Status of Physician documentation “template” being developed by CMS • Prior Authorization of certain DMEPOS • Regulatory changes involving Off-the-Shelf Orthotics

17. Competitive bidding of DME • Round II and the future of Medicare competitive acquisition of DME • National pricing based on competitive bidding • Impact of coding on access to DMEPOS care

18. Questions and Discussion