Brace Yourself: Decreased Payments Might be Coming

As we warned at the end of last month, the times they are a-changin’. You’re likely well aware of the legislation that could do away with the Sustainable Growth Rate (SGR)—and extend the therapy cap for another two years. We had hoped to have better news for you at this point, but we’re still hanging tight while the Senate sings their own off-key version of Wilson Phillips’ “Hold On.”

It’s April 14, 2015. That means the therapy cap exceptions process has expired and SGR is in full effect, thereby reducing all Medicare Physician Fee Schedule (MPFS) payments by 21%. Thankfully, the Centers for Medicare & Medicaid Services (CMS) has stepped in to temporarily hold all claims for services provided on or after April 1, 2015, as well as any claims that include the KX modifier. So, if the Senate votes in favor of the bill by tomorrow, April 15, everything will go back to normal. No harm, no foul. If they don’t vote by tomorrow, then CMS will have to administer a “rolling hold” in an effort to both supply cash flow to providers and minimize automatic claims reprocessing should Congress pass legislation reversing the fee schedule changes. That means CMS will release the held claims one day at a time—on a first-in, first-out basis—and pay on them at the new-and-reduced rate. At the same time, CMS will hold all new claims, so that they maintain 10 days’ worth of claims at any given time.

Now, let’s say Congress fails to pass the bill or makes alterations to it. This will unleash a different series of consequences—and that’s a course we can’t chart until we’re actually in that boat.

If you’ve already submitted claims for the affected dates of service, no action is necessary on your part. But keep in mind that at the moment, providers still have the option to hold claims until Congress votes on the bill. Because Medicare allows providers up to one year after the date of treatment to submit claims, WebPT suggests that you hold claims until the dust settles—but only if your clinic can handle the temporary hit to your bottom line.

Like the pirate’s code, our recommendation is more of a guideline than a rule. Ultimately, you’ll need to determine the best course of action for your practice. If you do hold on to your claims, know that your payments will be delayed; but should Congress pass the bill by tomorrow, you’ll receive the full amount of each claim without having to wait for reprocessing.

We’ll keep you updated as we have more information, so stay tuned, folks.