Physicians Look Ahead to Increased Medicaid Primary Care Fees; Official “To Do” List on How to Make it Happen

Physicians looking forward to the new payment increases for Medicaid primary care services now have access to more answers as we head into the new year and the increased payments become available. Both physicians and states must take a few steps in order to obtain the increased amounts provided under sec. 1202 of the Health Care Education and Reconciliation Act (HCERA) (P.L. 111-152). CMS has just released two new fact sheets with questions and answers to help physicians and states ready themselves for the new rates as indicated in the final rule released November 6.

Per the final rule, all state Medicaid programs are required to increase their payments for certain primary care services to equal or exceed the Medicare rate.  Increased rates apply to services performed by or under the supervision of physicians. Physicians in both fee-for-service as well as managed care organizations are eligible for the increased rates, which are federally funded up to the difference between a state’s Medicaid fees that were in effect on July 1, 2009 and Medicare fees in 2013 and 2014. Before physicians receive this payment, however, a few things must happen.

First, states must submit and CMS must approve a state plan amendment (SPA) outlining the methodology for calculating the payments. The SPA must identify every eligible primary care code that the state will reimburse at the Medicare rates and identify any of those codes that were not covered in 2009. It also must state how the agency will apply the geographic and site-of-service adjustments. To aid states in the creation of these SPAs, CMS has issued a state plan preprint for this purpose.

Because states may not have the proper procedures in place when providers become eligible for these increased rates on January 1, 2013, CMS has indicated that physicians will continue to be paid at the 2012 rate until the state has its attestation procedures and higher fee schedule rates in place, but can expect to receive a supplemental payment once these requirements are met. States may draw federal financial participation for these higher payments only after the SPA methodology is approved.

States aren’t the only ones with requirements. Physicians also have some work cut out for them. To qualify for the increased payment, a physician must attest either to board certification in internal medicine, family medicine, pediatrics, or a related subspecialty or to at least 60 percent of the previous year’s Medicaid billings consisting of the designated primary care services identified by the E&M codes specified in the regulation.

There are a few caveats. A physician who maintains one of the eligible certificates but actually practices in a non-eligible specialty should not self-attest to eligibility for higher payments. On the flip side, a physician who is not board certified in the eligible specialty but who practices in a community as a family practitioner could self-attest to a specialty designation of family medicine, internal medicine, or pediatric medicine and meet the 60% claims history requirement.

While states have been given the authority to automate physician self-attestations, the increased payments would be at risk if the state agency finds that the attestation was inaccurate. Under the final rule, states are required to conduct a review of a statistically valid sample of physicians who have self-attested to qualifying for the increased payments. Both physicians and the state Medicaid agency must keep all necessary information to support their attestation and remain eligible for the increased reimbursement rates. States will be required to repay erroneous payments that are found through the pool of sampled providers and must submit plans for corrective action to reduce errors.