SGR and Fiscal Cliff



On January 1st at approximately 2:00am, the United States Senate, by a vote of 89 – 8 adopted legislation that prevents most taxpayers from experiencing a tax increase; prevents the scheduled 26.5% SGR related cut in physician fee schedule payments and delays (until early March) the 2% across-the-board cut in Medicare payments due to sequestration.

In lieu of the 26.5% SGR cut, the Senate approved a one-year freeze in the Medicare conversion factor used to calculate Medicare Physician Fee Schedule payments.  The Senate also approved a one-year extension of several Medicare payment policies that were set to expire today.  Finally, the Senate approved a series of payment reductions in other provider payments as a way to “pay for” the SGR fix.

A list of the Medicare provisions “extended” is below, along with the list of payment reductions the Senate approved as “offsets”.

Last evening, the House of Representatives in a bi-partisan vote of 257 – 167, the House of Representatives voted to support the Fiscal Cliff/SGR legislation passed earlier today by the Senate.

The legislation was unchanged from the version passed by the Senate.  Therefore, it can immediately go to the President for his signature, which is expected.  To recap:

1.    The SGR cut of 26.5% is rescinded and the Conversion Factor for the physician fee schedule will be frozen for one year.
2.    The 2% sequestration cut that was to take effect later this week is been temporarily postponed until early March.  The next Congress will have to determine whether to allow sequestration to take place or replace sequestration with other cuts in federal spending or higher taxes.
Here are some of the other information regarding the passed bill.

Medicare Provider Payment provisions extended as part of the Fiscal Cliff compromise.

Work Geographic Adjustment. This provision extends the existing 1.0 floor on the “physician work” index through December 31, 2013.

Payment for Outpatient Therapy Services. This provision extends the exception process through December 31, 2013. The provision also extends the cap to services received in hospital outpatient departments only through December 31, 2013.

Ambulance Add-On Payments. This provision extends the add-on payment for ground including in super rural areas, through December 31, 2013, and the air ambulance add-on until June 30, 2013.

Extension of Medicare inpatient hospital payment adjustment for low volume hospitals. This provision extends the payment adjustment until December 31, 2013.

Extension of the Medicare-Dependent hospital (MDH) program. This provision extends
the MDH program until October 1, 2013.

Other Health Provisions used to offset the cost of a temporary SGR fix.

Documentation and Coding (DCI) adjustment. This provision will phase in the recoupment of past
overpayments to hospitals made as a result of the transition to Medicare Severity Diagnosis Related
Groups (MS-DRGs). Savings: $10.5 billion.

Rebase End Stage Renal Disease (ESRD) payments. This provision incorporates recommendations from the General Accountability Office by re-pricing the bundled payment to take into account changes in behavior and utilization of drugs for dialysis. Savings: $4.9 billion.

Therapy Multiple Procedure Payment reduction. This provision further reduces payment for
subsequent therapies when therapies are provided on the same day. Savings: $1.8 billion.

Payment for Certain Radiology Services. This provision would equalize payments for stereotactic
radiosurgery services provided under Medicare hospital outpatient payment system. Savings: $0.3

Adjustment of Equipment Utilization Rate for Advance Imagining Services. This policy would increase the utilization factor used in the setting of payment for imaging services in Medicare from 75% to 90%. Savings: $0.8 billion.

Competitive Prices for Diabetic Supplies. This proposal would apply competitive bidding to diabetic test strips purchased at retail pharmacies. Savings: $0.6 billion.

Adjust Payment Adjustment for Non-Emergency Ambulance Transports For ESRD Beneficiaries. This provision reduces the payment rates for ambulance services by 10% for individuals with ESRD obtaining non-emergency basic life support services involving transport, based on a recent General Accountability Office report. Savings: $0.3 billion

Increase statute of limitations for recovering overpayments. This provision increases the statute of
limitations to recover overpayments from three to five years, based on recommendations from the
Office of Inspector General at the Department of Health and Human Services. Savings: $0.5 billion.

Medicare Improvement Fund. This provision eliminates funding for the Medicare Improvement Fund. Savings: $1.7 billion.

Rebase Medicaid Disproportionate Share Hospital (DSH) payments to extend the changes from the Affordable Care Act (ACA) for an additional year. This proposal rebases DSH allotments to maintain the level of changes achieved in the ACA, and determines future allotments off of the rebased level using current law methodology. Savings: $4.2 billion.

Repeal of Class Program. The provision repeals the Community Living Assistance Services and Supports (CLASS) program established by the Affordable Care Act. This provision has no scoring implications.

Coding Intensity Adjustment. Under current law, Medicare Advantage plans receive risk-adjustment
payments that are further adjustment to reflect differences in coding practices between Medicare fee-for- service and Medicare Advantage. This provision increases this coding intensity adjustment. Savings: $2 billion.

Consumer Operated and Oriented Plan (CO-OP). This provision will rescind all unobligated CO-OP funds under section 1332(g) of the Affordable Care Act. This provision also creates a contingency fund of 10 percent of the current unobligated funds to be used to further assist currently approved co-ops that have already been created. The provision does not take away any obligated CO-OP funds. Savings: $2.3 billion

Sustainable Growth Rate (SGR) Update


Attention Health Professionals:  Information Regarding the 2013 Medicare Physician Fee Schedule

The negative update of 27% under current law for the 2013 Medicare Physician Fee Schedule is scheduled to take effect on January 1, 2013.

Medicare Physician Fee Schedule claims for services rendered on or before December 31, 2012, are unaffected by the 2013 payment cut and will be processed and paid under normal procedures and time frames.

The Administration is disappointed that Congress has failed to pass a solution to eliminate the sustainable growth rate (SGR) formula-driven cuts, and has put payments for health care for Medicare beneficiaries at risk. We continue to urge Congress to take action to ensure these cuts do not take effect. Given the current progress with the legislation, CMS must take steps to implement the negative update.

Under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt. CMS will notify you on or before January 11, 2013, with more information about the status of Congressional action to avert the negative update and next steps.   is site down peta dunia satelit .