Ms. Davis says the flawed database miscalculated the amounts non-PAR phy-
“We try so hard to do it right,
and Medicare just makes it impossible.”
sicians can collect up front from patients — called the limiting charge for unas- signed claims — factoring in the EHR and PQRS penalties that kicked in this year for all physicians. Starting in 2015, Medicare docks physician pay for those who do not satisfactorily report to PQRS or become meaningful users of EHRs. The penalties apply regardless of whether physicians choose “participating” or “nonparticipating” status in Medicare. (See “Know Your Medicare Status,” op- posite page.) The patient responsibility amounts printed on Medicare EOBs were off by
anything from a few cents to a few dollars, depending on the service. Across doz- ens of claims and for more expensive services, that can add up, Ms. Davis says. It wasn’t until TMA staff investigated the issue and pressed CMS and Novitas
(Texas’ Medicare contractor) that notifications finally appeared in late February and late March across Medicare contractors’ websites nationwide explaining the problem and putting a fix in the works to correct the EOBs. CMS would not comment on the issue. Given the complexity of Medicare’s formulas and web of penalties, physicians
rely on Medicare and its contractors for accuracy, says Donna Kinney, director of research and data analysis in TMA’s Division of Medical Economics. (See “Hard Math,” page 29.) Charge too much, and physicians face financial penalties, fraud charges, and possible exclusion from Medicare. Charge too little, and physicians lose the difference.
DUE DILIGENCE THWARTED Ms. Ream says she’s careful to follow the fee schedule and collect nothing be- yond the limiting charge. Not having an EHR system, she also knew to use the amount that included the penalty. The fee schedule mistake thwarted her diligence. “We try so hard to do it right, and Medicare just makes it impossible,” Ms.
Ream said. “It’s so frustrating because this was something CMS did. But we are the ones spending time on the phone figuring it out. And our patients get these notices, too. I would have had to write every one of them a 17-cent check. Can you imagine that and how expensive it would be?” According to a March 23 notice on Novitas’ website, corrected claims started going out at the beginning of March. Ms. Ream had yet to see them. TMA continues to monitor the issue. At press time, it was also unclear wheth-
er CMS and Medicare contractors stemmed the issue before it would appear on patients’ quarterly benefit notices, and if not, whether they would correct any affected patient EOBs. The SGR repeal legislation won’t immediately resolve these kinds of issues,
Ms. Kinney says. But over the long haul, it will mitigate them. The legislation somewhat simplifies the current fee-for-service system of
penalties but not until 2019. It consolidates Medicare’s various quality report- ing programs and their penalties into a single Merit-Based Incentive Payment System, or MIPS. (See “R.I.P. SGR,” June 2015 Texas Medicine, pages 26–37.) Over the past decade, Ms. Ream says she’s had to print the fee schedule sev-
eral times a year to keep up with Medicare’s adjustments and Congress’ patch- work politics. When she spoke to Texas Medicine — just before SGR repeal — she said it was “hard to even think about what the new fee schedule would be with a 21-percent cut. I really hope we don’t have to see it.” Now, she won’t. n
Amy Lynn Sorrel is associate editor of Texas Medicine. You can reach her by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at
amy.sorrel@
texmed.org.
30 TEXAS MEDICINE July 2015
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