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Budget Act Extends GPCI Floor

The Bipartisan Budget Act of 2018 featured an extension of the physician work geographic price cost index (GPCI) floor. As the work GPCI is a component of the Medicare payment formula, this declaration positively impacts physician reimbursement. On March 20, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum instructing Medicare contractors to reprocess claims affected by the law.

The good news is that physicians in Alabama, Georgia, Kentucky, Mississippi, and Tennessee will see increases in Medicare reimbursement dating back to January 1, 2018 dates of service; the bad news is that more than 90 days’ worth of claims have already been paid – and are candidates for reprocessing. Because the boost in reimbursement is so small – pennies, in some cases, this situation could prove to be a challenge.

The Medicare Administrative Contractors (MACs) are required to make the change, however, there is no guidance on the details of the so-called “automatic reprocessing.” CMS’ instructions include: “Contractors shall automatically reprocess…claims for localities and states impacted by the Work GPCI Floor fee increase for dates of service in calendar year 2018.” While details aren’t provided, a subsequent guidance by CMS is critical for physicians to review: “Contractors shall reprocess [the] claims [that] cannot be automatically reprocessed only if brought to your attention.” This statement inherently gives latitude to Medicare contractors to avoid the payment boost – unless you raise the issue. If your Medicare business is small – or the financial impact minor – you may be relieved that the contactor can’t “automatically reprocess” your claims. However, for physicians who a significant Medicare patient population, or those who perform surgeries, procedures, and other high-dollar services on Medicare patients, this instruction should set off alarm bells – and drive you to action.

Although CMS instructs the MACs to begin reprocessing claims as soon as possible, they are given six months to initiate the process. Therefore, if you haven’t seen evidence of the additional monies owed to you (particularly if the “old” fee schedule continues to be perpetuated), take action by proactively bringing the issue to the contractor’s attention, as CMS instructs.

Ultimately, this boost in payment – albeit small – is beneficial to physicians in the long-term. However, it could possibly be up to you to capture the advantage of the payment boost from the previous three months’ worth of claims.

Editor's Note:

On April 5, the Palmetto GBA announced, "Due to the retroactive effective dates of these provisions, your Medicare Administrative Contractor (MAC) will reprocess Medicare FFS claims impacted by this legislation. You do not need to take any action." See full details here.


About The Author

Elizabeth Woodcock is the founder and principal of Woodcock & Associates. She has focused on medical practice operations and revenue cycle management for more than 25 years. She has led educational sessions for a multitude of national professional associations and specialty societies, and consulted for clients as diverse as a solo orthopaedic surgeon in rural Georgia to the Mayo Clinic. She is author or co-author of 17 best-selling practice management books, to include Mastering Patient Flow and The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid. Elizabeth is a Fellow in the American College of Medical Practice Executives and a Certified Professional Coder. In addition to a Bachelor of Arts from Duke University, she completed a Master of Business Administration in healthcare management from The Wharton School of Business of the University of Pennsylvania. She is currently a doctoral student at the Bloomberg School of Public Health of Johns Hopkins University.

The contents of The Sentinel are intended for educational/informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and/or change over time.

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