On June 25, 2010, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule, available here,1 updating payment policies and payment rates that are paid under the Medicare Physician Fee Schedule (MPFS). In addition, the proposed rule implements several key provisions of the Patient Protection and Affordable Care Act (PPACA) of 2010. The PPACA provisions included in the proposed rule are focused on the following:
- expanding access to care;
- improving payment accuracy; and
- primary care and prevention.
The proposed policies and payment rates will apply to payments under the MPFS for services furnished on or after January 1, 2011.
The proposed rule includes guidance on complying with Stark disclosure requirements for physicians referring CT, MRI, and positron emission tomography (PET) services under the in-office ancillary services exception. The proposed rule has not expanded the list of diagnostic procedures to which the disclosure requirements apply; however, CMS has requested comments on whether to expand to radiology and other imaging procedures. CMS has proposed that the referring physician be required to provide the patient with a list of 10 alternate suppliers who provide the same imaging services within a 25 mile radius of the physician’s office. This list must include name, address, phone number, and distance of each supplier. At present, the proposed rule only requires the list to include suppliers; however, CMS is soliciting comments on whether to expand the list to “providers of services.” CMS is interested in determining whether an expansion of the list would benefit patients in choosing an alternative entity for imaging services.
The proposed rule also includes implementation of PPACA provisions that aim to eliminate out-of-pocket costs for Medicare beneficiaries for preventative services, including the new annual wellness visit. Currently, Medicare pays for a one-time-only initial preventative physical exam known as IPPE or the “Welcome to Medicare Visit.” The annual wellness visit will supplement the IPPE and will allow the physician and patient to develop a personalized prevention plan. The proposed rule provides that the annual wellness visit must:
- establish or update medical and family history;
- list current medical providers, suppliers and prescribed medications;
- record height, weight, BMI, blood pressure, etc.;
- detect any cognitive impairment;
- establish a 5-10 year screening schedule; and
- furnish personal health advice and coordinate referrals and health education.
Moreover, in an effort to insure that Medicare beneficiaries have access to medical care, the proposed rule implements incentive payments to primary care practitioners. PPACA provides for incentive payments equaling 10 percent of a primary care physician’s allowed charges for primary care services under Medicare Part B. Incentive payments would be made quarterly based on the primary care services furnished. PPACA defines “primary care practitioners” as physicians, nurse practitioners, clinical nurse specialists and physician assistants who have a specialty designation of family medicine, internal medicine, geriatric medicine or pediatric medicine. To be eligible, the primary care services provided must account for at least 60 percent of the practitioner’s allowed charges under Medicare Part B for a prior year determined by the Secretary of the Department of Health and Human Services.
Unfortunately, the proposed rule projects a 6.1 percent reduction to physician payment rates for 2011 under the sustainable growth rate (SGR) formula. The SGR formula has called for systematic physician payment rate cuts every year beginning in 2002; however, at present, these cuts have been averted by short-term legislative action.
The proposed rule will be published in the July 13, 2010, issue of the Federal Register. CMS will accept comments on the proposed rule until August 24, 2010, and a final rule is to be issued on or about November 1, 2010.
