Private Payers Incorrectly Utilize Local Medicare Fee Schedules Which Include Budget Neutrality and DRA Adjustments
The ACR has learned of a problem with private payer fee schedules that are attached to the Medicare Physician Fee Schedule (MPFS). Some ACR members are experiencing difficulty in developing appropriate contract payments with a number of private payers, as the private payers are utilizing the local Medicare fee schedules that include the budget neutral adjustments in the professional component and capped rates due to the Deficit Reduction Act (DRA) in the technical component.
However, it was not intended for managed care/private payer plans to include these adjustments in their fee schedules. Private payers should utilize the unadjusted fee schedules, which may be accessed here.
In response to comments from providers who were concerned about the potential adverse affect of applying the budget neutrality adjustor to all physician work RVUs, the 2007 Medicare Physician Fee Schedule Final Rule, published Dec. 1, 2006, states the following:
“We share the commenters’ concerns about transparency and recognize the Medicare PFS is used by other payors and for other purposes than just Medicare payments. To maintain a high level of transparency in the fee schedule, the Addendum B published in this rule will show the RVUs without the budget neutrality adjustment applied. This will serve as a reference for any interested party and should help to minimize any confusion about the unadjusted codes.”
Local Medicare contractors are not required by the Centers for Medicare and Medicaid Services (CMS) to post the unadjusted national Medical Physician Fee Schedule on their Web sites, however, the ACR is working with its Carrier Advisory Committee (CAC) and Managed Care Networks to accomplish this. The ACR is also making direct contact with private payers to correct this problem.
The ACR urges all members to bring this issue to the attention of your group contracting representatives to ensure that you are receiving appropriate reimbursement. In addition, we would appreciate your assistance in determining how widespread this problem is.
Please e-mail Kathryn Keysor at kkeysor@acr.org if you are having a problem with your private payers using the adjusted fee schedule as the basis for your reimbursement.