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PCPs in Line for Higher Medicaid Payments

A final rule puts Medicare and Medicaid on a level playing field for certain primary care.

By Lanaya Sandberg, MBA, CPCO

The Centers for Medicare & Medicaid Services (CMS) published a final rule last fall mandating payers reimburse qualified healthcare providers for certain primary care services rendered to Medicaid enrollees at rates not less than the Medicare rates for 2013 and 2014, using the 2009 Medicare Physician Fee Schedule conversion factor. Fees for the administration of vaccines under the Vaccines for Children program have been updated, as well.
This rule is important because Medicaid reimbursement has always been significantly less than that for Medicare. Primary care physicians (PCP) may now benefit from an increase in Medicaid reimbursement.
PCPs Score
The accessibility of primary care is especially important for Medicaid enrollees. As the United States moves closer to Medicaid expansion in 2014, there must be an appropriate number of PCPs who accept Medicaid enrollees. A goal of this rule is to encourage PCPs to participate in Medicaid by increasing reimbursement. This rule provides the opportunity to improve clinical outcomes and quality while reducing overall healthcare costs through more efficient coordination of care.
Effective Date
The provisions of this rule were effective Jan. 1, 2013, but states had until March 31, 2013 to file a state plan amendment with CMS. Regardless, payers are required to adhere to the effective date for claims payment. For example, if a payer updates its claims system with the new rates in July 2013, the payer will have to reprocess claims or issue a settlement check retroactively to include dates of service on or after Jan. 1, 2013.
Primary Care Services
The applicable codes for the affected primary care services are:

  • Evaluation and management (E/M) codes 99201-99499; and
  • Vaccine administration codes 90460, 90461, 90471, 90472, 90473, and 90474.

Qualified Providers
This rule applies to providers with a specialty of family medicine, general internal medicine, pediatric medicine, or a subspecialty within these specialties accepted by the American Board of Medical Specialties, American Board of Physician Specialties, or the American Osteopathic Association. Providers must self-attest that they are board certified and/or have provided E/M services and vaccine administration accounting for at least 60 percent of the codes they have billed for their Medicaid patients.
Exception: This rule is not applicable to federally qualified health centers and rural health clinics.
What Do Providers Need to Know and Do?
To ensure proper Medicaid payments, PCPs should become familiar with this rule and ensure compliance officers or compliance contacts and counsel are educated in its requirements.
More good advice:

  • As states have various options for implementing the requirements of this rule, research the approach your state has chosen to pursue; and
  • Reach out to the payers with which you are contracted and ask them when they intend to load the updated rates in their claims systems, and when they will be reprocessing claims. Request a copy of their written policies relative to this rule. Keep in mind: These requirements also apply to payers with which you are not contracted, so you should reach out to them, as well.

If you are interested in learning more about this rule, refer to RIN 0938-AQ63 in the Federal Register at: https://federalregister.gov/a/2012-26507.

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Note: The views and opinions expressed in this article are those of the author and do not reflect the official policy or position of any organization. The information contained in this article is to alert you to compliance developments and should not be considered legal advice.
Lanaya Sandberg, MBA, CPCO, is a network manager and responsible for national provider and vendor contracting.
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