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2016 Medicare Participation

 

Every year physicians have the opportunity to become participating providers with Medicare. The open enrollment period began November 14, and ends on December 31, 2015. A participating provider enters into an agreement to accept the Medicare-approved amount as full payment for services and supplies covered under Part B. A participating provider receives five percent more reimbursement than a non-participating provider. The participation agreement will automatically renew each year. However, if there is a name or EIN (tax identification number) change, you will need to complete a new participation agreement.

 

Physicians and practitioners who do not wish to enroll in the Medicare program may "opt-out" of Medicare. This means that neither the physician, nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician out-of-pocket and neither party is reimbursed by Medicare. A private contract is signed between the physician and the beneficiary that states, that neither one can receive payment from Medicare for the services that were performed. The physician or practitioner must submit an affidavit to Medicare expressing his/her decision to opt-out of the program.

 

Filing an Affidavit to Opt Out

Physicians and non-physician practitioners who want to opt-out must file a written affidavit with Medicare in which they agree to opt-out of Medicare and to meet certain other criteria.

In general, the law requires that during the opt out period, physicians and non-physician practitioners who have filed affidavits opting out of Medicare must sign private contracts with all Medicare beneficiaries to whom they furnish services that would otherwise be covered by Medicare, except those who are in need of emergency or urgently needed care.

They cannot sign such contracts with beneficiaries in need of emergency or urgent care services.

Moreover, physicians and non-physician practitioners who opt-out cannot choose to opt-out of Medicare for some Medicare beneficiaries but not others; or for some services and not others.

 

2016 Medicare Fee Schedule Update

As reported previously in the Wesgram, the 2016 Medicare fee schedule does not contain the 0.5% increase called for by the law that repealed Medicare's SGR; but instead is now a 0.3% pay decrease.

The Protecting Access to Medicare Act of 2014 (PAMA) and the Achieving a Better Life Experience Act of 2014 (ABLE) set certain Medicare reimbursement policies that trumped the positive updates in the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

While physicians are no longer being hit by the 21% pay cut that would have been implemented had the SGR legislation not passed, most physicians still will receive the 0.3% cut.

Per CMS (information from their website), the conversion factor for 2015 is 35.9335, while the 2016 conversion factor will be 35.8279.

The Affordable Care Act instructed CMS to identify "misvalued codes" in the Physician Fee Schedule, which CMS does through the annual rulemaking process.  

In the Protecting Access to Medicare Act of 2014 (PAMA), Congress set a target for adjustments to misvalued codes in the fee schedule for calendar years 2017 through 2020, with a target amount of 0.5 percent of the estimated expenditures under the PFS for each of those four years. Subsequently, the Achieving a Better Life Experience Act of 2014 (ABLE)  accelerated the application of the target by specifying it would apply for calendar years 2016 through 2018, and increasing the target to 1.0  percent for 2016. If the estimated net reductions in PFS expenditures resulting from changes in values for misvalued codes in 2016 are not equal to or greater than the target, a reduction equal to the percentage difference between target and the estimated net reduction in expenditures resulting from misvalued code reductions must be made to all PFS services.