Industry News Highlights

Pioneer ACO Changes for PHP, PPP, SMPC

The boards for PHP, PPP, and SMPC have made a decision to transition the groups out of the Pioneer Accountable Care Organization (PACO) program into a Medicare Shared Savings Program (MSSP).  The MSSP is an ACO program managed through the Centers of Medicare and Medicaid Services (CMS) which carries less financial risk.  The MSSP program will take effect January 1, 2014.

The factors which led to the boards’ decision include :

  • Data lag from CMS
  • Benchmarking variances
  • Geographical determinations not considered
  • Maintaining financial viability for the IPAs

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House Releases SGR Replacement Legislation

The House Energy and Commerce Committee passed a bipartisan legislation to repeal Medicare’s sustainable growth-rate formula and to replace it with a much more stable system of payments.  The House voted 51-0 to approve the bill after many months of deliberation.  This draft legislation is “the latest step in the transparent process to reform the system and reward providers for delivering high-quality, efficient health care.”

Legislative summary

The SGR replacement legislation provides for a modified fee-for-service (FFS) program in two phases:

Phase I – Involves a period of payment stability during which an improved FFS program would be developed, including the establishment of quality goals and measurement methods.

Phase II – Will introduce quality measurements to traditional FFS payments.

At any time during Phases I or II, the legislation allows providers to “opt-out” of the modified FFS system for alternative payment models (e.g., accountable care organizations, bundled payments, or patient-centered medical homes).  


AAFP Checklist for Applying for Higher Medicaid Rate

The AFP has put together a check list to assist family providers in receiving a higher payment rate.  The increased payment will bring Medicaid payment rates in line with Medicare payment levels for 2013 and 2014.  This check list will help family providers to self-attest for the program.  In order to qualify for the higher payment rate, providers must be trained in the specialty categories of family medicine, internal medicine, or pediatrics and can self-attest that they are:

  • 60 percent of all Medicaid services they bill or provide in a managed care environment are for specified evaluation and management codes or vaccine administration codes, or
  • They are board-certified in one of the primary care specialties


Tentative Timeline for Implementing the Revised Form for Medicare Claims

The Centers of Medicare and Medicaid Services (CMS) is changing the CMS 1500 claim form to a new version 02/12.  The claim form is the standard claim form used by a non-institutional provider or suppler to bill Medicare carriers and DMERCs.  Medicare anticipates implementing the revised CMS 1500 claim form (version 02/12) as follows:

  • January 6, 2014: Medicare begins receiving and processing paper claims submitted on the revised CMS 1500 claim form (version 02/12).
  • January 6 through March 31, 2014: Dual use period during which Medicare continues to receive and process paper claims submitted on the old CMS 1500 claim form (version 08/05).
  • April 1, 2014: Medicare receives and processes paper claims submitted only on the revised CMS 1500 claim form (version 02/12).

These dates are tentative and subject to change. CMS will provide more information as it is available. The new CMS 1500 claim form.