How do Medical Group Practices Prepare for Health Insurance Reform?

Strategies that medical practices should consider!

Now that the Patient Protection and Affordable Care Act has become a reality, let’s NOT talk about it!  Let’s NOT give you another outline of the details in the bill.  I leave this up to others.  Many will have much to say about it.

In nearly 2600 pages of the original bill, and the amendments to it, there are plenty of things that will directly affect Solo Physician and Medical Group Practices.  One example of note, Primary Care Providers will be reimbursed at Medicare rates for services provided to Medicaid patients!

What are some of the other direct impacts on my practice?

  • Physicians and other providers applying for Medicare participation will be required to have a Compliance Program in place.  It is unknown if this requirement will extend to an existing Medicare participating medical group which is adding a physician or other practitioner who has not previously participated in Medicare – but it might!
  • The limitation on submitting claims to Medicare has been reduced to one calendar year from the date of service.
  • Overpayments from Medicare must be returned within 60 days of the date of determination that there was an overpayment.  Penalties are 3 times the amount owed.
  • A provider’s enrollment can be revoked if he or she does not maintain a record of physician referrals for home health and DME services, and make the records available to CMS when requested.
  • There must be a face-to-face encounter between the provider and the patient when home health or DME is ordered.  (HHS can also extend this requirement to other services)
  • There will be a new protocol for providers to self-disclose violations of the physician self-referral regulations.
  • States may use Recovery Audit Contractors (RAC’s) for audits of state Medicaid programs.
  • A Provider may be terminated from Medicare when terminated from a state Medicaid program.
  • PQRI Measures and HITECH Act Meaningful Use criteria will be integrated, to the extent possible, in the near future.
  • There will be no copayment required from Medicare beneficiaries for preventive services graded A or B by the US Preventive Services Task Force.  Medicare will pay 100% of the Medicare Allowable for these services.
  • Medicare will reduce payments to physicians not participating in PQRI by 1.5% in 2015 and by 2.0% in 2016.

So what should I be doing?

  • Develop and implement effective Compliance Policies and Procedures that includes internal monitoring such as a risk-based coding and documentation audit.
  • If you are a Medicare participating provider, begin reporting PQRI measures.
  • Make sure your billing and accounts receivable practices include timely filing of claims and timely refunds to government payors when overpayments are identified.
  • Ensure your EHR system is capable of meeting the Meaningful Use Criteria.
  • Remember that the year 2010 is possibly the one year to “move most aggressively into the future”, because the future is arriving whether you are prepared or not!

Tell us what you’re doing to prepare!


When you need proven expertise and performance

Dr. Gunter G. Fuchs

Dr. Gunter G. Fuchs has over 30 years of clinical, administrative, consulting, acute care operations, and strategic planning experience in domestic and international healthcare.

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