by Jackie Lucas, Medical billing Manager
Mandatory Payment Reduction of 2% Continues until Further Notice for the Medicare FFS Program – “Sequestration”
Medicare Fee-For-Service (FFS) claims will continue to incur a two percent reduction in Medicare payment until further notice. The claims payment adjustment will continue to be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments. Though beneficiary payments for deductibles and coinsurance are not subject to the two percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the two percent reduction. CMS encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to continue discussions with beneficiaries on the impact of sequestration on Medicare’s reimbursement. Questions about reimbursement should be directed to your Medicare Administrative Contractor (http://go.usa.gov/cymuF).
Railroad Medicare’s (RMC) Medical Review (MR) unit will begin a service-specific review of Evaluation and Management (E/M) CPT code 99285, emergency department visit, requiring highly complex medical decision making. RMC selected this code based on internal data analysis. At the conclusion of this review, they will publish their findings on their website.
On March 27, 2016 electronic prescribing of all controlled and non-controlled prescriptions (including syringes and medical devices), commonly referred to as e-prescribing will become mandatory for all prescribers in New York State. This regulation is one of the multiple sections of the Internet System for Over-Prescribing Act (I-STOP) program passed in 2012. Most providers who use an electronic health record (EHR) can easily e-prescribe using the same software. Those who do not have an EHR system in place will have to purchase an electronic prescribing computer application for one of the various software platforms based on their practice and e-prescribing needs. For more information on electronic prescribing of controlled substances please visit
Changes to Performance and Quality Programs
Pay for performance (P4P) 2016—Focus will be on Primary Care Physicians (PCP’s)
- Only PCP’s will be eligible to participate
- P4P incentive payments will be contingent on PCP meeting threshold targets
- The 2016 P4P program includes Medicaid members
The following measures have been added to the program:
- HEDIS Medication Management for people with Asthma 75% Compliance
- Measures replaced: HEDIS Appropriate Asthma Medications
The following measures have been eliminated from the program:
- HEDIS Monitoring Persistent Meds ACE or ARB
- HEDIS follow-up with 7 days after hospitalization for Mental Illness
For more information about Blue Cross’s 2016 P4P program, log onto bcbswny.com/provider and go to My Account>Reports>pay for performance>2016 P4P.
In July 2015, we notified you that effective July 1, 2015 Medicaid would no longer reimburse partial Medicare Part B coinsurance amounts (20% of the Part B coinsurance). Medicaid did not implement this change until December 17, 2015. In February, Medicaid began making claim adjustments for dates of service 7/1/15 through their revision date of 12/17/15. Weekly Medicaid EFT’s/checks will be reduced until all of these claims are re-processed.
For Billing questions, please contact Jackie Lucas at 716-348-3923 or firstname.lastname@example.org