Physician Law : Pennsylvania Health Law Lawyer & Attorney : Fox Rothschild LLP : serving Philadelphia, Pittsburgh, Allentown, Erie, Upper Darby Twp

On November 24, 2009, the U.S. House of Representatives passed the Medicare Physician Payment Reform Act" (H.R. 3961) which would repeal the scheduled 21% fee reduction scheduled for January 2010.  The legislation would also permanently replace the existing Sustainable Growth Rate (SGR) formula with a new formula that, according to the House summary:

• Removes items such as drugs and laboratory services not paid directly to practitioners from spending targets;
• Allows spending on most services to grow at the rate of GDP plus 1 percentage point per year (compared to GDP without any adjustment today);
• Allows spending on primary and preventive care services to grow at GDP plus 2 percent per year; and
• Encourages coordinated, innovative care by allowing Accountable Care Organizations to be responsible for their own growth paths, irrespective of reductions or increases that apply elsewhere in the system.
   

The bill is now on the Senate calendar for consideration.

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Despite efforts by Senator Harry Reid to pass legislation which would have effectively frozen Medicare payment rates for physicians, it looks like Congress will once again look to freeze physician payment rates with a one-year patch. According to an article published by the Wall Street Journal, Senator Reid’s proposed bill would have permanently prevented Medicare payment cuts to doctors. However, the bill was estimated to cost $247 billion over ten years and Senator Reid was unable to secure the votes necessary to get the bill out of the Senate. The bad news for physicians is that there’s no permanent fix for the sustainable growth rate formula in the Medicare Physician Fee Schedule. The good news however is that Senator Reid has indicated an intention to pass a measure which would forestall the projected 21% decease in physician payments expected for 2010.

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According to a recent article published on AIS Health.com, Blues plans are increasingly turning to radiology management firms to help manage costly imaging services.  This is a new twist on the old "managed care" concept and, once adopted by the Blues, other major payors can be expected to follow.   Physicians who provide imaging services are well advised to monitor this trend closely.

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Under what it is calling its Provencare program, Geisinger Health System is now offering patients what amounts to a ninety warranty on surgical care.  Under the program - something like capitation and use of clinical protocols - insurers are charged a flat fee for which patients receive unlimited follow up care after surgery.  Geisinger intends to control costs by developing and applying specific clinical protocols depending on the patient's condition.  So far Geisinger has only actually contracted with its own insurance unit but hopes the concept will gain in popularity. 

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The Medicare incident-to rules permit a physician to bill for the services of auxiliary personnel as if the physician performed those services himself.  You may already know that the incident-to rules require a physician to be present in the office suite and immediately available to assist while auxiliary personnel are performing incident-to services in the office.  But, did you know that you could be supervising incident-to services without even knowing it? 

In a recent federal District Court whistleblower case out of Hawaii, a court rejected a whistleblower physician's claim that he could not have been the supervising physician for incident-to services since he was not made aware by his group practice that the services would be billed to Medicare under his provider number.   Under the incident -to rules, any physician in a "physician directed clinic" may supervise incident-to services and the court agreed with the defense that a physician in a "physician directed clinic" need not have specific knowledge that he will be the supervising physician for billing purposes.  The court's opinion can be found here.

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Both the House and the Senate have now passed the Tax Relief and Health Care Act of 2006 which, among other things, would eliminate the 5% cut in Medicare physician reimbursement that was to take effect in January 2006.  The Bill is on its way to the President for signature. The text of the Bill can be viewed by clicking here.

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Pending PA legislation would limit most insurance refund demands and retroactive payment denials by third party payors to a one-year lookback period except where fraud or miscoding occurs. The full text of the bill can be viewed here:physicianlaw.foxrothschild.com/HB2178P4462(1).pdf . The bill was passed by the House by a vote of 195 to 2 on June 30. It's still pending before the Senate and was referred to the Senate Banking Committee on July 5. For more information on this possible development, contact Bill Maruca at Fox Rothschild LLP.

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