Medicare Payment Schedule for 2012 and Claims Processing Hold

While Congress delayed the 27.4% Medicare fee cut that was to have gone into effect on January 1, 2012, it is important to understand that other payment factors from the Medicare physician payment final rule will affect the 2012 fee schedule. In other words, even though the SGR-driven fee cut was averted for two months the 2012 fee schedule is not the same as the 2011 fee schedule. For example, the conversion factor was changed from $33.9764 to $34.0376. Other changes include: an extension of the floor on the work geographic practice cost index (GPCI); multiple procedure payment logic; electronic prescribing and quality reporting; and corrected relative values for certain services. Therefore, the 2011 schedule is not the schedule that will be implemented in 2012 and the currently posted 2012 schedule (that includes the 27.4% fee cut) is not the schedule that will be implemented.

Because Highmark and other carriers have not had time to implement the Medicare payment delay, passed by Congress and signed into law by President Obama on December 23, MSNJ encourages members not to submit Medicare claims until the correct payment schedule is posted. CMS estimates that carriers will have the corrected schedule posted by January 11. MSNJ will inform members when Highmark has posted the corrected schedule. Highmark previously announced a hold on claims until January 17, so the claims would not be processed in any event. Moreover, if practices submit claims with an amount less that what they are entitled to, Highmark is under no compulsion to pay the increased amount and will not reprocess these claims.

For details review AMA’s memo dated November 4 and CMS’s January 4 Federal Register correction notice to the 2012 final rule that modifies the relative values for a number of services. Also see CMS’s revised relative value file reflecting both the corrections and the legislation that delayed the 27.4% cut.


About MSNJ

Founded in 1766, the Medical Society of New Jersey is the oldest professional society in the United States. The organization and its dues-paying members are dedicated to a healthy New Jersey, working to ensure the sanctity of the physician–patient relationship. In representing all medical disciplines, MSNJ advocates for the rights of patients and physicians alike, for the delivery of the highest quality medical care. This allows response to the patients’ individual, varied needs, in an ethical and compassionate environment, in order to create a healthy Garden State and healthy citizens.

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