As happens every year, Congress stepped in at the last minute and blocked the Sustainable Growth Rate (SGR) cuts in Medicare payments to physicians.  On the afternoon of January 1, 2013, the House of Representatives adopted legislation passed earlier that day by the Senate, the "American Taxpayer Relief Act of 2012.” The bill prevented a plunge over the “fiscal cliff” by postponing across-the-board spending reductions and also overrode the 26.5 percent Medicare fee schedule cut that technically had already gone into effect on the morning of passage.   Congress’ action replaced the SGR reduction with a zero percent update for services provided from January 1, 2013, through December 31, 2013. Because of adjustments in the practice expense component of the anesthesia conversion factor (CF), the 2013 national average CF is $0.50 higher than last year’s CF, i.e., $21.9243.  This is 38 percent higher than the $15.93 CF announced in November 2012.   Actual...

In any financial transaction, the person holding the money is at an advantage.  Getting money back from someone who should not have been paid is harder than not making the payment in the first place.   CMS knows this, and that is why it is placing a new emphasis on prepayment review of claims.  Originally slated to begin on January 1, 2012 the prepayment review initiative will now formally launch in June.  The number of prepayment reviews is going to increase from 1.2 million to 2.7 million claims per year. There is a large amount of taxpayer dollars at stake.  In 2011, the Medicare fee-for-service improper payment rate was 8.6 percent, or $28.8 billion in estimated erroneous claims payments.  Medicaid adds another $21.9 billion.  During 2011, CMS recovered $5.6 billion in fraudulent payments, an increase of 167 percent over 2008. The increase in recoveries is attributable in major part to the $350...

Written by: Neda Mirafzali, Esq Kathryn Hickner-Cruz, EsqThe Health Law Partners, P.C., Southfield, MISince the passage of the Affordable Care Act1 and the establishment of the Medicare Shared Savings Program (the “Shared Savings Program”), ACOs have become the new hot topic.Section 3022 of the Affordable Care Act provides that Medicare shall establish the Shared Savings Program and that healthcare providers and suppliers will participate in the Shared Savings Program through ACOs. According to CMS, “ACOs create incentives for healthcare providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities. The Shared Savings Program will reward ACOs that lower growth in healthcare costs while meeting performance standards on quality of care and putting patients first.”2 If an ACO saves money by providing patients with efficient care, then the ACOs can share in a percentage of the savings with Medicare. However, should an ACO fail...