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News of the Day ... In Perspective

1/10/2007

Physicians have until Feb 14 to change Medicare participation status; fee schedule changes and new Medicare Advantage Plans may spur them to do so

Ordinarily, the period for Medicare enrollment changes extends from mid-November to Dec 31. However, because of a change in the Medicare Physician Fee Schedule (MPFS), the period has been extended to Feb 14, 2007.

“Existing Par physicians who no longer wish to be Par must notify their Medicare contractor in writing of their decision to terminate their Par agreement.”

Physicians cannot opt out of Medicare if they are bound by a participating physician agreement (Form CMS-460). Only “non-participating” physicians may opt out. There are a couple of new reasons why physicians may want to do this.

The Tax Relief and Health Care Act of 2006 set the 2007 conversion factor for physician payment at the 2006 level, ($38.8975), reversing the statutorily mandated 5.0 percent “negative update.” However, it does not maintain physician payments at 2006 levels.

Other factors that affect payment include: changes in the practice-expense RVU-setting methodology and practice expense RVUs, re-weighting of geographic adjustment factors, limits on payments for imaging procedures, and coding “refinements.”

Another reason that physicians may want to become Non-Par or opted out is the potential effect of changes in Medicare Part C made by the Medicare Modernization Act (MMA).

With Medicare Advantage plans, patients basically transfer their Medicare benefit to a private company, which assumes responsibility for payments. Some of these plans are HMOs, and the services of non-contracted (“out of network”) physicians may not be covered by Medicare.

A new type of plan under the MMA is the Medicare Advantage Private Fee for Service Plan (MAPFFS), which does not have a network. One such plan, the Human Gold Choice Plan, is said to be creating a system of “deemed participation.” A physician is “deemed” to have accepted the Plan’s conditions by accepting even one enrolled patient. A resolution by the New Mexico Medical Society, accepted at the AMA 2006 interim meeting, asks the AMA to investigate the legality of such “implied contracts.”

According to the Plan’s website, enrollees “can choose to see any provider who accepts Medicare patients. But make sure the providers you see agree to Humana’s terms and payment conditions.”

Another MAPFFS being marketed in eight states (Arizona, Florida, Georgia, Louisiana, Nevada, South Carolina, Texas, and Utah), by Universal Health Care calls itself the “Any, Any, Any Plan.” Enrollees can see “any Medicare participating provider.”

“At present, it is unclear to us what obligations physicians may incur by accepting these patients,” stated AAPS Executive Director Jane M. Orient, M.D. They need to find this out from the Plan. The doctor cannot just decide to turn down a network, but may have to reject patients one by one.

The plans could be very popular because they promise, in some cases, to refund the patient’s $93.50 monthly Part B premium. They will still make “tons of money”—in the words of a representative at an enrollment seminar—by collecting between $700 and $1,200 per month from Medicare for each enrollee.

Physicians who are opted out would be protected from unexpected obligations but could still see patients who value their services on a private basis. The situation of non-Par physicians is not clear at present.

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