From the Wisconsin Medical Society

After passing the U.S. House of Representatives last week, H.R. 2: “The Medicare Access and CHIP Reauthorization Act” (MACRA), which would repeal the flawed sustainable growth rate (SGR) formula, has been put on hold until the U.S. Senate reconvenes April 13.

The current SGR patch is set to expire March 31, and the Centers for Medicare and Medicaid Services (CMS) has instructed carriers to hold claims for services provided on or after April 1 for 10 days in order to prevent the 21 percent pay cut from being implemented before Congress can act. By law, claims cannot be paid sooner than 14 calendar days upon receipt, so the 10-business day hold should have little impact on Medicare remittance short-term.

In the meantime, the American Medical Association (AMA) is advising practices to continue charging the current rates or to defer submitting claims.

“By law, Medicare is required to pay physicians the lesser of the submitted charge or the Medicare approved amount. For this reason, the AMA is advising against submitting claims with reduced amounts reflecting the 21 percent cut. Instead, we recommend physicians either continue charging the current 2015 rates for April dates of service or defer submitting claims until after final action on the legislation,” said Terri Marchiori, director of federation relations for the AMA. “In the unexpected event that Congress allows the 21 percent cut to take effect, Medicare would pay physicians at the reduced amount no matter what the physician billed and no further action would be necessary. However, non-participating physicians who have collected balance billing amounts for unassigned claims based on the currently-allowed amount could be required to make refunds to their patients based on new, lower balance billing limits.”

Provisions in the bill include:

  • Repeal of the SGR methodology and stabilized Medicare physician payments moving forward.
  • A new 5 percent incentive for participating in alternative payment models like accountable care organizations or medical homes.
  • A new value-based incentive payment system—the Merit-Based Incentive Payment System—that would streamline and harmonize all of the current value incentives such as Meaningful Use (MU), Physician Quality Reporting System (PQRS) and Value Modifier (VM).

Congress has temporarily fixed the flawed SGR formula with 17 patches in the last 11 years. Physicians are urged to contact their Senators about repealing the flawed formula once and for all.