What’s an allergist to do on April 1?

March 30, 2015

What’s an allergist to do on April 1?

On March 26, by a vote of 392 – 37, the House of Representatives passed H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015, which, among other things, would permanently repeal and replace the SGR formula. It would also provide for physician pay increases of 0.5 percent per year from July 2015 through 2019

The bill is now pending in the Senate for consideration. The Senate adjourned at approximately 4 a.m. on March 27 without taking any action on H.R. 2. The Senate is now on a two week “state work period” and will reconvene on April 13.

The Senate Leadership has said that the SGR bill will be one of the first orders of business on their agenda when the Senate reconvenes. Furthermore, we fully expect that when the Senate does act in concert with the House, any SGR fix they adopt will be retroactive to April 1.

The President has said that he will sign H.R. 2 as soon as it gets to his desk.

We believe the long-term prospects for this bill are positive but the SGR cut scheduled to take effect on April 1 will occur.

As you know, Medicare Contractors hold claims for 14 days before processing. So all claims with a date of service beginning on April 1 which will be subject to the SGR cut, will not be processed by the Medicare Contractors until April 15. Technically, this means that the Senate could reconvene on April 13, as scheduled, debate and pass H.R. 2 and have it on the President’s desk prior to the April 15.

If the scenario outlined above occurs, Medicare Contractors could then process those early April claims using the payment rates in effect on March 31 rather than using the SGR reduced amounts. By holding claims in this manner, Medicare would avoid the need to reprocess these claims.

What are your options?

  1. You can submit your April 1 and later Medicare claims as usual, have them held by the Contractor and trust that Congress passes the SGR fix legislation prior to the Contractor processing those claims. If Congress does not act in time and the Contractor does process your claims at the SGR reduced rate, and Congress retroactively fixes the SGR problem, Medicare will reprocess those claims. CMS will provide instructions if this is necessary.

  2. You could hold your early April Medicare claims until Congress retroactively fixes the SGR and then submit your claims once the legislation is passed, thus avoiding the need to reprocess. Obviously this may have cash flow implications so each practice will have to consider the cash flow ramifications of holding claims.

If Congress fixes this retroactively, you may also need to bill your patients for any additional copay because the copay you can collect on your early April patient visits will initially be based on the SGR reduced payment rate. A retroactive SGR fix would raise the payment for those early April visits allowing you to go back to your patients and collect a higher copay – if you choose.

Again, we remain optimistic that Congress will adopt and the President will sign into law a permanent SGR fix. Unfortunately, we cannot guarantee the exact timing of those actions and how this might affect the processing of Medicare claims.

ACAAI will continue to advocate for adoption of a permanent SGR solution and encourage the Senate to act as quickly as possible in order to minimize any disruption in physician payments.