CMS Updates Medicare Part B Claims Processing Guidance Related to SGR Enactment

Dan Ciolek

The Centers of Medicare and Medicaid Services (CMS) provided the following announcement related to the processing of Medicare Part B claims with dates of service on or after April 1, 2015. With the enactment of the Medicare Access and CHIP Reauthorization Act of 2015 yesterday, CMS will resume processing claims according to the law’s provisions. Prior AHCA announcements regarding this topic are located here and here. 

The SGR provisions include an extension for the Part B therapy caps exceptions process through December 31, 2017. This means that it will no longer be appropriate for providers to issue advance beneficiary notices (ABN’s) to beneficiaries receiving medically necessary services above the $1940 therapy caps, since providers can use the exceptions process for therapy services above the threshold. More information about therapy cap related ABNs can be found on the CMS website.

 

Attention Health Professionals: Information Regarding the 

Medicare Access and CHIP Reauthorization Act of 2015 

CMS – April 13, 2015 -- On April 14 , 2015, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015; the President is expected to sign it shortly.  This law eliminates the negative update of 21% scheduled to take effect as of April 1, 2015, for the Medicare Physician Fee Schedule.   In addition, provisions allowing for exceptions to the therapy cap, add-on payments for ambulance services, payments for low volume hospitals, and payments for Medicare dependent hospitals that expired on April 1 have been extended.  CMS will immediately begin work to implement these provisions.

In an effort to minimize financial effects on providers, CMS previously instituted a 10-business day processing hold for all impacted claims with dates of service April 1, 2015, and later.  While the Medicare Administrative Contractors (MACs) have been instructed to implement the rates in the legislation, a small volume of claims will be processed at the reduced rate based on the negative update amount.   The MACs will automatically reprocess claims paid at the reduced rate with the new payment rate.  
No action is necessary from providers who have already submitted claims for the impacted dates of service.