2013 could put more cash in your pocket


Primary care physicians may well see payments increase under several federal programs next year.

dollar sign

One change waves a carrot at primary care physicians in the hopes of encouraging Medicaid program participation. The move comes at a time, in some states, when a growing number of physicians in private practice are contemplating whether to limit or no longer accept Medicare and Medicaid patients because of low reimbursement rates and burdensome governmental requirements.

Add to rising costs and regulatory pressures the threat posed by the Medicare sustainable growth rate (SGR) formula, and you have some physicians reassessing their ability to remain in business at all. The formula is the method used by the Centers for Medicare & Medicaid (CMS) in an effort to prevent the annual Medicare expense per beneficiary from rising above the growth in gross domestic product – a method that may result in a yearly payment adjustment for physician services.

A physician shortage just as the insured population is expected to explode under health reform could be problematic. Some 15 million people will be added to Medicaid alone beginning in 2014 because anyone earning up to 133 percent of the federal poverty level will be eligible to enroll. The number of additional enrollees will swell to 24 million by 2016, according to the CMS Office of the Actuary.

The actual number of recipients will be subject to how many states ultimately decide to opt out of the Medicaid expansion. But even those states that refuse to accept the federal funding can opt in to the program at any future time.

Medicaid fees

To increase participation in the assistance program, the Affordable Care Act requires that primary care physicians serving Medicaid patients be reimbursed, at a minimum, at Medicare levels in 2013 and 2014.

Primary care physicians are defined as those practicing family medicine, general internal medicine, pediatric medicine and related subspecialties.

The provision extends to payments on a fee-for-service basis or through a Medicaid managed-care plan. Solely the federal government will fund the increased payment. No matching payments are required from the states.

Critics point to the concern that the federal funding is for only two years, leaving questions about future reimbursement rates. Further, the results of November’s presidential election may well determine the Affordable Care Act’s ultimate fate.

Vaccines for Children fee

Rising also in 2013 are the regional maximum fees that primary care physicians can charge for administering vaccines to eligible children under the federal Vaccines for Children (VFC) program. The rates have not been updated since the vaccination program was established in 1994. The new rates will be adjusted using the Medicare Economic Index.

Nonphysician practitioners, such as nurse practitioners and physician assistants, also are eligible for the increased vaccine payment. However, the vaccine must be administered under the personal supervision of an eligible primary care physician and billed under that physician’s program enrollment number.

Federally qualified health centers and rural health clinics are paid under a different structure and are not eligible under this program.

Medicare physician fee schedule

A stated goal of the Centers for Medicare & Medicaid has been to develop initiatives that focus on providing payments to primary care physicians that more accurately reflect the value of their services. The proposed 2013 Medicare Physician Fee Schedule does just that.

While some specialties are staring at a decrease in payments of up to 19 percent, total allowed charges by family physicians are estimated to rise approximately 7 percent. The expected impact on other primary care specialties includes a 5 percent increase for internal medicine, pediatrics and nurse practitioners; 4 percent for geriatrics; and 3 percent for physical/occupational therapy and physician assistants.

For 2013, CMS has proposed a new procedure code that will pay community physicians or qualified nonphysician practitioners for coordinating care during the 30 days after their patients are discharged from a hospital or skilled nursing facility. This is a one-time payment per patient, per discharge.

The following elements will be required to qualify for the payment:

  • Communication with the patient or caregiver within two business days of discharge either in person, by telephone or electronically
  • Medical decision-making of moderate or high complexity during the service period
  • A face-to-face evaluation and management visit with the patient in the 30 days prior to the transition in care or within 14 business days following the transition in care

The final Medicare physician fee schedule is expected to be released in November. Of course, the projected increases don’t take into account any reduction that might occur in the unlikely event that Congress fails to act on the impending sustainable growth factor cut.