On April 1, 2015, CMS issued a special edition of its MLN Connects Provider eNews publication addressing the SGR-triggered payment reduction of 21 percent for physicians and additional provisions that were scheduled to expire on April 1, 2015.  The MLN issuance addresses the negative 21 percent payment rate adjustment required under current law for the Medicare Physician Fee Schedule (MPFS) that is scheduled to take effect on April 1, 2015.  The House of Representatives has passed legislation replacing the SGR.  The Senate has yet to act.  To allow additional time for Congressional action, CMS explains that, starting April 1, 2015, it is holding claims for a short period of time to minimize potential claims reprocessing and disruption of physician cash flow in the event the Senate also passes legislation revising the 21 percent payment reduction.  CMS explains that it will provide further guidance to physicians by April 11, 2015.

In addition, in the MLN publication, CMS addresses other provisions affecting providers that were also set to expire by April 1, 2015, including exceptions to the outpatient therapy caps, add-on payments for ambulance services, payments for low volume hospitals, payments for Medicare dependent hospitals, and Recovery Auditor Inpatient Hospital Status Reviews.

Exceptions Process for Medicare Part B Outpatient Therapy Caps.

These therapy caps are the annual per beneficiary cap amounts for occupational therapy and for physical therapy and speech-language pathology services combined.  Therapy caps are determined for each calendar year, but an exception process has been in place for necessary services exceeding the cap.  CMS explains that based on current law, exceptions will be considered only for dates of service through March 31, 2015.  Services thereafter will be subject to a dollar limitation.

Add-On Payments for Ambulance Services.

Currently, Medicare provides for an increase in the ambulance fee schedule amounts (both base rate and mileage) for covered ground ambulance transports that originate in rural areas by three percent and covered ground ambulance transports that originate in urban areas by two percent.  In addition, Medicare currently provides for an increase of 22.6 percent in the base rate of the ambulance fee schedule amount for covered ground ambulance transports that originate in areas designated as super rural.  CMS confirms that these provisions expire as of April 1, 2015.

Payments for Low-Volume Hospitals and Medicare Dependent Hospitals.

The Affordable Care Act and subsequent legislation made temporary changes to the low-volume hospital payment adjustment for hospitals that meet certain discharge and mileage criteria.  The Medicare Dependent Hospital program also provides enhanced payment to support small rural hospitals for which Medicare patients make up a significant percentage of inpatient days or discharges.  CMS confirms that these temporary changes to the low-volume hospital adjustment and the Medicare Dependent Hospital provision expire on April 1, 2015.

Recovery Auditor Inpatient Hospital Status Reviews.

CMS announced that the Probe and Educate program under the controversial Two-Midnight Rule will be extended through April 30, 2015.  Prior to this announcement, the Probe and Educate period was scheduled to conclude on March 31, 2015.  CMS further clarified that Recovery Auditors (RACs) are prohibited from reviewing inpatient hospital patient status determinations for admissions occurring between October 1, 2013 and April 30, 2015.  On its Inpatient Hospital Reviews webpage, CMS further explains that the one month extension of the Probe and Educate Program is due to potential Congressional action on H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015, which proposes to extend the Probe and Educate period.

To view the MLN update, please click here