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CMS instructs Medicare contractors to hold claims for 10 days

January 03, 2013
Area(s) of Interest: Payor Issues and Reimbursement 


On January 3, the Centers for Medicare and Medicaid Services (CMS) released instructions to Medicare contractors for implementation of the revised fee schedule.


On January 1 , Congress passed HR 8, the American Taxpayer Relief Act, narrowly averting the so-called "fiscal cliff." The bill includes a one-year Medicare fee-for-service physician payment freeze, meaning the 26.5 percent sustainable growth rate (SGR) cut has been averted, for now.


In order to allow sufficient time to develop, test, and implement the revised 2013 Medicare physician fee schedule, Medicare contractors have been instructed that they can hold claims with January 2013 dates of service for up to 10 business days. CMS expects these claims to be released into processing no later than January 16, 2013.


The claim hold should have minimal impact on physician cash flow because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 for paper claims) after the date of receipt.


Based on prior history of similar fee schedule updates, the California Medical Association (CMA) believes that physicians may expect to see claims paid in approximately 21 days, rather than the usual 14 days.


According to CMS, Medicare contractors will be posting the new payment rates on their websites no later than January 23, 2013.


The 2013 fee schedule will not be exactly the same as the 2012 fee schedule. Although Congress stopped the 26.5 percent SGR cut, there were other components of the fee schedule formula that affect payment that may have changed, such as the relative value units (RVUs).


Physicians have the option of holding claims and submitting them after the new fee schedule is released. If you choose to submit claims in the interim, CMA suggests that both participating and non-participating physicians bill their usual and customary fees-for-services to Medicare. Billing at your customary fee ensures that Medicare pays the highest amount possible when the claim is processed.

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