CMS Open Door Forum Current Schedule
| New Medicare Developments
Physician Quality Reporting Initiative (PQRI) | Electronic Prescribing Incentive (eRx) Program
Medicare and Tobacco-use Cessation | The HITECH Foundation for Information Exchange
Recovery Audit Contractors | Medicare Opt-Out Instructions | Palmetto GBA - Medicare Contractor
Medicare Payment Alert
On June 25 President Obama signed into law the "Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010." This law establishes a 2.2% update to the Medicare Physician Fee Schedule (MPFS) payment rates retroactive from June 1 through November 30, 2010. CMS has directed Medicare contractors to discontinue processing claims at the negative update rates (the 21% cut enacted June 1) and to temporarily hold all claims for services rendered June 1 and later, until the new 2.2% update rates are tested and loaded into the Medicare contractors' claims processing systems. Effective testing of the new 2.2% update will ensure that claims are correctly paid at the new rates. CMS expects to begin processing claims at the new rates no later than July 1. Claims for services rendered prior to June 1, 2010, will continue to be processed and paid as usual.
Claims containing June 2010 dates of service which have been paid at the negative update rates will be reprocessed as soon as possible. Under current law, Medicare payments to physicians and other providers paid under the MPFS are based upon the lesser of the submitted charge on the claim or the MPFS amount. Claims containing June dates of service that were submitted with charges greater than or equal to the new 2.2% update rates will be automatically reprocessed. Affected physicians/providers who submitted claims containing June dates of service with charges less than the 2.2% update amount will need to contact their local Medicare contractor to request an adjustment. Submitted charges on claims cannot be altered without a request from the physician/provider. Physicians/providers should not resubmit claims already submitted to their Medicare contractor.
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CMS Open Door Forum - Current Schedule
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New Medicare Developments
PECOS Enrollment UPDATE from AMA (7/1/10): Due to significant AMA advocacy, Centers for Medicare and Medicaid Services (CMS) announced on June 30th, that claims that list the name and NPI of a referring / ordering physician who is not yet enrolled in PECOS will NOT see their claims reject beginning on this date. CMS will provide more information about when they will begin rejecting claims in the near future. We continue to urge them not to reject any for at least 6 more months. For more information we recommend physicians review the CMS June 30th press release.
Earlier this month, CMS published an Interim Final Rule, requiring any physician who refers or orders services (DMEPOS, home health, specialist services [not defined by CMS], lab or imaging) to be enrolled with Medicare in the PECOS system by July 6, 2010. This includes any physician who has not submitted an updated enrollment application to Medicare in the past 6 years or who has not reported changes in their enrollment information that occurred during this time. All physicians must list on their claims the legal name and NPI of the physician who referred/ordered to them for services.
Physician Quality Reporting Initiative (PQRI)
2010 Physician Quality Reporting Initiative Educational Products are Now Available
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the posting of 2010 Physician Quality Reporting Initiative (PQRI) educational products to the PQRI webpage. To access the 2010 PQRI educational products, visit the following page www.cms.hhs.gov/PQRI/02_Spotlight.asp#TopOfPage on the CMS website. Once on the Spotlight page, view the listing of educational products and the corresponding webpages where they can be found.
Further information on the 2010 PQRI Program may be found in the final 2010 Medicare Physician Fee Schedule rule with comment period (74 FR 61788 through 61861) that was published in the Federal Register on October 30, 2009. The final rule can be found on the Physician Quality Reporting Initiative webpage at www.cms.hhs.gov/PQRI on the CMS website, click on the Statute/Regulations/Program Instructions section page at left.
Reporting for the 2010 PQRI begins January 1, 2010. Please note there is no need to sign up or pre-register in order to participate.
2010 Electronic Prescribing Incentive (eRx) Program
2010 Electronic Prescribing Incentive (eRx) Educational Products are Now Available
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the posting of 2010 Electronic Prescribing Incentive (eRx) Program educational products to the eRx webpage. To access the 2010 eRx educational products, visit the following page www.cms.hhs.gov/PQRI/02_Spotlight.asp#TopOfPage on the CMS website. Once on the Spotlight page, view the listing of educational products and the corresponding webpages they can be found on.
Further information on the 2010 eRx Incentive Program may be found in the final 2010 Medicare Physician Fee Schedule rule with comment period (74 FR 61788 through 61861) that was published in the Federal Register on October 30, 2009. The final rule can be found on the Electronic Prescribing Incentive Program webpage at www.cms.hhs.gov/ERxIncentive on the CMS website, click on the Statute/Regulations/Program Instructions section page at left.
Reporting for the 2010 eRx begins January 1, 2010. Please note there is no need to sign up or pre-register in order to participate.
Medicare and Tobacco-use Cessation
Medicare provides coverage of smoking and tobacco-use cessation counseling for beneficiaries who use tobacco and have a disease or adverse health effect linked to tobacco use, or who take certain therapeutic agents whose metabolism or dosage is affected by tobacco use.
As a health care professional who provides care to patients with Medicare, you can help protect the health of your patients by educating them about their risk factors and encourage them to take advantage of Medicare-covered smoking and tobacco-use cessation counseling benefits.
CMS has developed several educational products related to Medicare-covered smoking and tobacco-use cessation counseling. Please visit the Medicare Learning Network for more information on these and other Medicare fee-for-service educational products.
The HITECH Foundation for Information Exchange
CMS Presentation on Medicare & Medicaid EHR Incentive
A Message from Dr. David Blumenthal, National Coordinator for Health Information Technology
As the many activities mandated by the HITECH Act move forward, I want to take a moment to share my vision of the overarching goal and some of its implications. Our goal, above all else, is to make care better for patients, and to make it patient-centered. Information policy and health IT policy should serve that goal.
A key premise: information should follow the patient, and artificial obstacles – technical, business related, bureaucratic – should not get in the way. As a doctor, I have many times wanted access to data that I knew were buried in the computers or paper records of another health system across town. Neither my care nor my patients were well served in those instances. That is what we must get beyond. That is the goal we will pursue, and it will inform all our policy choices now and going forward. This means that information exchange must cross institutional and business boundaries. Because that is what patients need. Exchange within business groups will not be sufficient – the goal is to have information flow seamlessly and effortlessly to every nook and cranny of our health system, when and where it is needed, just like the blood within our arteries and veins meets our bodies’ vital needs.
If we are to reap the benefit of information exchange, Americans must also be assured that the most advanced technology and proven business practices will be employed to secure the privacy and security of their personal health information, both within and across electronic systems, and that persons and organizations who hold personal health data are trustworthy custodians of the information. We must have comprehensive, clear, and sustainable policies that strengthen existing protections, fill gaps as they emerge, fortify new opportunities for patients’ access to and control of their information, and align with evolving technologies. I will devote a separate letter to this critical issue and the many activities mandated by the HITECH Act that we are developing.
On the question of exchange, however, the HITECH Act is pretty specific about eliminating inappropriate barriers.
It squarely tackles the commercial barriers. The HITECH Act calls for the “development of a nationwide health information technology infrastructure that allows for the electronic use and exchange of information and that…promotes a more effective marketplace, greater competition...[and] increased consumer choice” among other goals. (Section 3001(b)) This means we cannot support arrangements that restrict the secure, private exchange of information required for patient care across provider or network boundaries. Some of these arrangements may improve care for those inside their walls. But ultimately, they have the potential to carve the nation up into disconnected silos of information, and thus, to undermine the vision of a secure, interoperable, nationwide health information infrastructure, which the law requires us to establish. Consumers, patients and their caretakers should never feel locked into a single health system or exchange arrangement because it does not permit or encourage the sharing of information.
It tackles the economic barriers. The HITECH Act incentives for providers and hospitals are powerful tools. While the official definition of “Meaningful Use” won’t be finalized until next year, the HITECH Act specifically highlights “information exchange” as one requirement for the incentives.
It tackles the technical barriers. The HITECH Act focuses on “interoperability” or “interoperable products.” In plain English, this means that our policies, programs, and incentives must aim for electronic health record (EHR) software and systems that can share information with different EHRs and networks so that information can follow patients wherever they go. And to build the pipelines to carry this information, HHS is directed to invest in the infrastructure to “support the nationwide electronic exchange and use of health information …including connecting health information exchanges…” (Section 3011) This means we will work with all our partners in the health and IT industries and with organizations that are committed to information sharing to develop the technologies and policies that can help us deliver information securely, privately, and accurately to whomever needs to see it on behalf of the patient’s health. We must ensure interoperability for the future.
It provides building blocks for information exchange across jurisdictions. The grants for states and state-designated entities in Section 3013 – which will total $564 million – target information exchange across boundaries, not only within each state but explicitly as part of a nationwide framework. We will start announcing the awards this winter. These grantees’ activities must support interoperability that lets patient data follow the patient across political and geographic boundaries. The grantees will be our partners in building the nationwide infrastructure mentioned previously.
In short, the HITECH Act not only authorizes but requires us to mobilize all our policies, programs, and incentives to give the American people the patient-centric care they deserve and expect.
I look forward to engaging all our partners in this unique opportunity.
David Blumenthal, M.D., M.P.P.
National Coordinator for Health Information Technology
U.S. Department of Health & Human Services
This letter is part of a series of ongoing updates from the National Coordinator for Health Information Technology. The Office of the National Coordinator for Health Information Technology (ONC) encourages you to share this information as we work together to enhance the quality, safety and value of care and the health of all Americans through the use of electronic health records and health information technology.
For more information and to receive regular updates from the Office of the National Coordinator for Health Information Technology, please subscribe to our Health IT News list
Recovery Audit Contractors
Medicare fee-for-service providers may be eligible for recovery audits by Recovery Audit Contractor (RAC) programs. To date, with some very limited exceptions, the RACs have not conducted any physician audits. They continue to focus on the hospitals. However, physicians should be aware that the RACs are approved to conduct physician audits and may do so at any time.
RACs in Hawaii: The Recovery Audit Contractor (RAC) for Hawaii is HealthDataInsights (HDI). For more information go to www.cms.hhs.gov/RAC or email CMS. To contact HDI go to www.racinfo.com
, email firstname.lastname@example.org, or call:
Part A/Hospice - (866) 590-5598 & Part B/DME - (866) 376-2319. Download presentations from HMA's recent RAC seminar for details: CMS HDI
Medicare Opt-Out Information
courtesy of Palmetto GBA
You can also download the Medicare Benefit Policy Manual see Chapter 15 - Covered Medical and Other Health Services, Section 40.1
Opt Out of Medicare Provider Enrollment: Instructions
As provided in § 4507 of the Balanced Budget Act of 1997, a private contract is a contract between a Medicare beneficiary and a physician or other practitioner who has ‘opted out’ of Medicare for two years for all covered items and services he or she furnishes to Medicare beneficiaries.
In a private contract, the Medicare beneficiary agrees to give up Medicare payment for services furnished by the physician or practitioner and to pay the physician or practitioner without regard to any limits that would otherwise apply to what the physician or practitioner could charge.
You can access complete lists of health professionals that have chosen to ‘opt out’ of the Medicare program in the Opt-out page of Palmetto GBA's Provider Enrollment section.
To opt out of Medicare
Participating physicians must first terminate their Medicare Part B participation agreement. Participating providers are only permitted to opt out at the beginning of each calendar quarter. Therfore, a provider must submit a valid Affidavit Form (PDF, 291 KB) at least 30 days before the first day of any quarter (January, April, July or October).
- Non-participating physicians and practitioners, however, may opt out at any time.
- Certain health care provider categories, however, cannot opt out of Medicare. These include chiropractors, doctors of oral surgery, physical therapists in independent practices, and occupational therapists in independent practices.
The Opt-Out contract is for a two-year period from the date the physician or practitioner files and signs an affidavit notifying Medicare that he or she has opted out of Medicare. After the two-year period is over, the physician or practitioner could elect to return to Medicare or to 'opt out' again.
Please send your opt-out request to:
J1 MAC - Palmetto GBA
P.O. Box 1508
Augusta, GA 30903-1508
Palmetto GBA - Medicare Contractor
Palmetto GBA is Hawaii’s Medicare administrative contractor, Part A effective 8/18/08 and Part B on 8/4/08. You are also encouraged to visit the Palmetto website for Medicare news and information, including Medicare fee schedules: www.PalmettoGBA.com/J1 or call the toll-free announcement line: 888-318-7246.
Palmetto GBA can be reached at 866-931-3901. Your local Palmetto contact is Jean Matsushita, phone 808-263-2770, fax 803-462-3945.
Palmetto GBA will also be conducting teleconferences and web workshops. Register on line and find more information at the PalmettoGBA.com event calendar or call 888-318-7246. You can also find Frequently Asked Questions online and sign up for email alerts.
Palmetto GBA Contact Details – Medicare Part B
The Interactive Voice Response (IVR) system is available 24 hours a day to obtain general information at 1-866-931-3903. Patient eligibility and claim status information is available 4:00 am - 7:00 pm PST (HI, NV, American Samoa) and 4:00 am - 5:00 pm PST (CA).
The Provider Contact Center (PCC) is here to help you with more complex or non-routine inquiries. Customer Service Representatives (CSR) will continue to be available between the hours of 7 a.m. through 5 p.m. (PST) Monday through Friday on a separate CSR only toll-free line at 1-866-931-3901. Below is a list on all PCC numbers:
Provider Contact Center:
Telephone Reopenings: 1-866-669-5543
The Telephone Reopening staff is here to assist you. Instead of a written redetermination, consider having your claim reopened! If there was a minor error or omission, you can request that Palmetto GBA reopen the claim for correction rather than going through the written appeals process.
Provider Enrollment: 1-866-931-3901
J1 MAC - Palmetto GBA
P.O. Box 1508
Augusta, GA 30903-1508
The Provider Enrollment Staff is here to help you to:
1) enroll in J1 Part B as a new provider
2) change your Medicare information, such as address or telephone information, opening or closing offices, and changes in authorized personnel or other important information
3) add or delete new members to your provider group
4) set up Electronic Funds Transfer
5) change your mailing address for Medicare checks (a.k.a., Pay To Address)
Electronic Data Interchange (EDI)
J1 MAC - Palmetto GBA
P.O. Box 100145
Columbia, SC 29202-3145
The EDI division encourages providers to submit their claims electronically and to utilize certain electronic features offered.
To contact J1 MAC Part B - Palmetto GBA in writing, please write to:
J1 MAC - Palmetto GBA
PO Box 1091
Augusta, GA 30903-1091