The U.S. Court of Federal Claims has denied two protests that were filed challenging a decision by the Centers for Medicare and Medicaid Services (CMS) to award the Medicare Administrative Contractor (MAC) contract for Medicare Parts A and B in Jurisdiction E to Noridian Administrative Services.

CMS and Noridian will now move forward to implement the new contract and expects this process to complete by mid-September 2013. SFMS/CMA has and will continue to work closely with CMS and the new contractor to ensure a smooth transition.

Jurisdiction E (previously called Jurisdiction 1) covers California, Nevada and Hawaii, as well as the U.S. territories of American Samoa, Guam and the Northern Mariana Islands. Jurisdiction E includes over 3.5 million Medicare fee-for-service beneficiaries, 500 Medicare hospitals and 86,500 physicians. MACs process Part A and Part B claims and perform other critical Medicare operational functions, including enrolling, educating and auditing Medicare providers.

The Centers for Medicare & Medicaid Services (CMS) has confirmed that the Medicare electronic health record (EHR) incentive program payments will be cut by 2% as required by the Sequestration Transparency Act.

The 2% "sequestration" cuts to Medicare are part of the $1.2 trillion in cuts required by the Sequestration Transparency Act, part of a deal worked out to end last year's debt-ceiling crisis.

According to CMS, the 2% reduction will be applied to Medicare EHR incentive payments for reporting periods that end on or after April 1, 2013. If the final day of the reporting period occurs before April 1, 2013, those incentive payments will not be subject to the reduction.

Medicaid (Medi-Cal in California) is exempt from the sequestration cuts.

Click here for more details on the sequestration cut as previously reported by SFMS. 

Click here for our Sequestration FAQ.

The Centers for Medicare & Medicaid Services (CMS) has identified technical issues with certain parts of the April 2013 quarterly systems release. The problem impacts claims received by the Medicare contractors (Palmetto GBA for California) on or after April 1, 2013.

The issues affect:

1.       All claims for assistant-at-surgery services

2.       All Ambulatory Surgical Center claims  

As a result of the system issues, CMS has instructed Medicare contractors to hold these types of claims until April 14, 2013, when system fixes are expected to be implemented.

Physicians should see minimal impact on the timeliness of these claims and their cash flow, as current law requires electronic claims to be held 14 calendar days, and paper claims for 29 days after the date of receipt. 

Click here to view the official CMS notice.

The Department of Health Care Services (DHCS) announced that the federal Centers for Medicare and Medicaid Services (CMS) has given approval to the project to require Medicare/Medi-Cal dual eligibles to enroll in a managed care plan. The project, which was previously known as the “Coordinated Care Initiative,” will now be called CalMediConnect. 

Size and Scope of the Project

The project will begin no sooner than October 1, 2013 and will impact approximately 450,000 duals in eight counties—Alameda, Los Angeles, Orange, Riverside, San Diego, San Mateo, San Bernardino, and Santa Clara. As a result of intensive SFMS/CMA advocacy, enrollment in Los Angeles County will be capped at 200,000 people.

Duals should receive their first notices about the transition in July 2013, with enrollments set to begin in October. How quickly enrollment happens will vary by county, from three months in San Mateo to 15 months in Los Angeles. In all other counties, the time frame will be 12 months.

Although patients will be passively enrolled, they will be able to opt out for their Medicare benefits at any time. There will be no lock-in period.

Continuity of Care Provisions

Under the terms of the MOU, duals who do enroll in managed care for their Medi-Cal and Medicare benefits will be able to continue seeing an existing Medicare provider for up to six months, even if that physician is not contracted with the health plan. Payment for the services will be at Medicare rates.

Also, in urgent or emergent situations, plans will be required to pay out-of-network providers at Medicare rates. This is a provision that SFMS/CMA fought for in the bill to protect physicians, especially those in emergency rooms.

Network Adequacy

SFMS/CMA is pleased that the plan includes extensive network adequacy and financial solvency requirements for the participating plans. This, again, was something we have fought for in the legislative process.

Next Steps

Now that DHCS and CMS have finalized their MOU, they will be jointly negotiating with health plans on a three-way contract. As noted above, duals should be receiving notifications about the change in July.

Medicare will begin denying claims on May 1, 2013, if the ordering/referring provider listed on the claim is not in the Provider Enrollment, Chain and Ownership System (PECOS), the database Medicare uses to track physicians and other providers.

If you bill Medicare, you are encouraged to note any Medicare EOBs with the remittance code N264 and/or N265, which may indicate that the ordering/referring provider on the claim is not yet in PECOS. These providers must take action to enroll in PECOS or future claims that you submit with these providers listed for dates of service on or after May 1 will be rejected.

Physicians and other providers are not required to enroll with Medicare to provide services in order to be listed in PECOS. Physicians who wish to be listed in PECOS solely for ordering/referring purposes may submit an enrollment application online via the PECOS website or by completing a CMS-855o paper enrollment application.

Click here to access the PECOS system to determine if you or another physician is currently enrolled in PECOS.

Click here to download a paper CMS-855o application.

Click here for the MLN Matters article for details about the update on PECOS and ordering/referring.