Federal Employees Health Benefits Program: limitation on physician charges and FEHB program payments--OPM. Interim regulation with request for comments

The Office of Personnel Management (OPM) is issuing an interim regulation that amends current Federal Employee Health Benefits (FEHB) Program regulations to require that the charges and FEHB fee-for-service plans' benefit payments for certain physician services furnished to retired enrolled individuals do not exceed the limits on charges and payments established under the Medicare fee schedule for physician services. The regulation authorizes the FEHB plans, under the oversight of OPM, to notify the Secretary of Health and Human Services (HHS) of a Medicare participating hospital, physician or supplier who knowingly and willfully fails to accept, on a repeated basis, the Medicare rate as payment in full from an FEHB plan. The regulation also authorizes the FEHB plans, under the oversight of OPM, to notify the Secretary of HHS of a Medicare nonparticipating physician or supplier who knowingly and willfully charges, on a repeated basis, more than the Medicare limiting charge amount (115 percent of the Medicare Nonparticipating Physician Fee Schedule amount).     

A tale of two bounties: the impact of competing fees on physician behavior

This study examines how the volume of privately insured services provided in hospital inpatient and outpatient departments changes in response to reductions in Medicare physician payments. We hypothesize that physicians consider relative payment rates when choosing which patients to treat in their practices. When Medicare reduces its payments for surgical procedures, as it did in the late 1980s, physicians are predicted to treat more privately insured patients because they become more lucrative. We use data from 182 hospitals for seventeen major procedures groups, covering a forty-five-month period between 1988 and 1991 that encom passes a twenty-four-month period before the reduction in Medicare fees and twenty-one months after the reduction. Our findings are consistent with the predictions for a number of procedure groups, but not for all of them. One implication of the findings is that societal savings from Medicare fee reductions are overstated if one does not also consider spillover effects in the private insurance market.     

Medicare program; physician liability on non-assigned claims--HCFA. Final rule

This rule establishes in regulations the circumstances in which a nonparticipating physician who does not accept Medicare assignment of a claim is required to refund to the beneficiary any amounts collected for physician services determined to be not reasonable and necessary. Its purpose is to extend limitation of liability protection to beneficiaries with non-assigned claims when the physician knew or could reasonably have been expected to know that Medicare would deny payment for the services. Physician appeal rights are also specified. This rule conforms our regulations to section 9332(c) of the Omnibus Budget Reconciliation Act of 1986.     

Medicare program; definition of surgical services--HCFA. Notice of definition of surgical services for physician volume performance standard rates for increase with comment

This notice announces the definition of surgical services for purposes of the performance standard rates of increase for expenditures and volume of physician services and the appropriate fee schedule updates under the Medicare Supplementary Medical Insurance (Part B) program as required by section 6102 of the Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239). Surgical services are defined as follows: All services currently classified as type of service "surgery" in the Medicare payment record that are performed by surgical specialists, including podiatrists and oral surgeons. All services currently classified as type of service "assistant at surgery" in Medicare payment records. This definition includes procedures recognized in the surgical section of Current Procedural Terminology published by the American Medical Association and certain other invasive procedures. This definition would not lead to payment differentials by physician specialty. Any differential in annual updates because of separate performance standard rates would be procedure-specific without regard to specialty.     

Medicare program; diagnosis codes on physician bills--HCFA. Final rule

This final rule implements certain provisions of section 1842(p) of the Social Security Act regarding diagnosis codes on physician bills. Under this final rule, each bill or request for payment for a service furnished by a physician under Medicare Part B must include appropriate diagnostic coding for the diagnosis or the symptoms of the illness or injury for which the Medicare beneficiary received care.     

Has PPS increased Medicare expenditures on physicians?

We use data from 1983 and 1985 on the volume of Medicare physician services to analyze whether Medicare's Prospective Payment System (PPS), which resulted in a significant decline in hospital spending, led to a partially offsetting increase in real expenditures for physician services. We also analyze the effect of increases in assignment rates, increasing incomes of the elderly, and other factors on real expenditures during this period. Our main conclusion is that PPS has at most a small positive effect on real physician expenditures. Because people spent less time in the hospital, Medicare physician spending declined; but because of incentives to shift radiology and other services out of the hospital, some of this decline was offset. We also conclude that the sharp increase in Medicare assignment rates over this period, along with the rising incomes of the elderly during this period, contributed to the observed growth.     

Medicare program; physician fee schedule update for calendar year 1996 and physician volume performance standard rates of increase for federal fiscal year 1996--HCFA. Final notice

This final notice announces the calendar year 1996 updates to the Medicare physician fee schedule and the Federal fiscal year 1996 volume performance standard rates of increase for expenditures for physicians' services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1848 (d) and (f), respectively, of the Social Security Act. The fee schedule update for calendar year 1996 is 3.8 percent for surgical services, -2.3 percent for primary care services, and 0.4 percent for other nonsurgical services. While it does not affect payment for any particular service, there was a 0.8 percent increase in the update for all physicians' services for 1996. The physician volume performance standard rates of increase for Federal fiscal year 1996 are -0.5 percent for surgical services, 9.3 percent for primary care services, 0.6 percent for other nonsurgical services, and a weighted average of 1.8 percent for all physicians' services. In our July 26, 1995 proposed rule concerning revisions to payment policies under the Medicare physician fee schedule for calendar year 1996, we proposed using category-specific volume and intensity growth allowances in calculating the default Medicare Volume Performance Standard (MVPS). We received 20 comments on this proposal. Since this proposal is related to the MVPS and this notice deals with MVPS issues, we are responding to those comments in this notice instead of in the final rule for the fee schedule entitled "Medicare Program; Revisions to Payment Policies and Adjustments to the Relative Value Units Under the Physician Fee Schedule for Calendar Year 1996" published elsewhere in this Federal Register issue.     

Stark II and physician compensation models: integrating business and legal issues

In March of 2004, the Centers for Medicare & Medicaid Services released new regulations that interpreted the Federal Physician Self Referral Act, otherwise known as Stark II. The new regulations, commonly referred to as the Phase II regulations, must be carefully considered when structuring physician compensation models. Stark II generally holds that physicians may not make a referral for designated health services to an entity with which they have a direct or indirect financial relationship. This Article outlines the provisions of Stark II that are applicable to physician compensation methodologies. In addition, the authors evaluate hypothetical transactions involving physician groups seeking viable compensation schemes and explore the validity and risks of each.     

Medicare program; revisions to payment policies under the physician fee schedule for calendar year 1999--HCFA. Proposed rule

This proposed rule would make several policy changes affecting Medicare Part B payment. The changes that relate to physician services include: resource-based practice expense relative value units, medical direction rules for anesthesia services, and payment for abnormal Pap smears. Also, we would rebase the Medicare Economic Index from a 1989 base year to a 1996 base year. Under the law, we are required to develop a resource-based system for determining practice expense relative value units. The Balanced Budget Act of 1997 (BBA 1997) delayed, for 1 year, implementation of the resource-based practice expense relative value units until January 1, 1999. Also, BBA 1997 revised our payment policy for nonphysician practitioners, for outpatient rehabilitation services, and for drugs and biologicals not paid on a cost or prospective payment basis. In addition, BBA 1997 permits certain physicians and practitioners to opt out of Medicare and furnish covered services to Medicare beneficiaries through private contracts. In addition, since we established the physician fee schedule on January 1, 1992, our experience indicates that some of our Part B payment policies need to be reconsidered. This proposed rule is intended to correct inequities in physician payment and solicits public comments on specific proposed policy changes.     

Medicare program; revisions to payment policies under the physician fee schedule for calendar year 2000. Health Care Financing Administration (HCFA), HHS. Final rule with comment period

This final rule makes several changes affecting Medicare Part B payment. The changes include: implementation of resource-based malpractice insurance relative value units (RVUs); refinement of resource-based practice expense RVUs; payment for physician pathology and independent laboratory services; discontinuous anesthesia time; diagnostic tests; prostate screening; use of CPT modifier -25; qualifications for nurse practitioners; an increase in the work RVUs for pediatric services; adjustments to the practice expense RVUs for physician interpretation of Pap smears; and revisions to the work RVUs for new and revised CPT codes for calendar year 1999 and a number of other changes relating to coding and payment. Furthermore, we are finalizing the 1999 interim physician work RVUs and are issuing interim RVUs for new and revised codes for 2000. This final rule solicits public comments on the second 5-year refinement of work RVUs for services furnished beginning January 1, 2002 and requests public comments on potentially misvalued work RVUs for all services in the CY 2000 physician fee schedule. This final rule also conforms the regulations to existing law and policy regarding: removal of the x-ray as a prerequisite for chiropractic manipulation; the exclusion of payment for assisted suicide; and optometrist services. This final rule also announces the calendar year 2000 Medicare physician fee schedule conversion factor under the Medicare Supplementary Insurance (Part B) program as required by section 1848(d) of the Social Security Act. The 2000 Medicare physician fee schedule conversion factor is $36.6137.     

Medicare program; payment for physician outpatient maintenance dialysis services and other physician services for ESRD patients--HCFA. Final rule

This final rule reinstates a modified version of the initial method of payment for physician dialysis services and clarifies and modifies some of the principles of the monthly capitation payment method. Under both the initial method and the monthly capitation payment method, we specify that, to be payable, physician services must meet certain requirements that distinguish services furnished to individual patients from services furnished to facilities that benefit the facilities' patients generally. The reinstatement of a modified version of the initial method is necessitated by a court order.     

Medicare and Medicaid programs: hospital outpatient prospective payment; ambulatory surgical center payment; hospital value-based purchasing program; physician self-referral; and patient notification requirements in provider agreements. Final rule with comment period

This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) for CY 2012 to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the OPPS. In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we set forth the relative payment weights and payment amounts for services furnished in ASCs, specific HCPCS codes to which these changes apply, and other ratesetting information for the CY 2012 ASC payment system. We are revising the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, adding new requirements for ASC Quality Reporting System, and making additional changes to provisions of the Hospital Inpatient Value-Based Purchasing (VBP) Program. We also are allowing eligible hospitals and CAHs participating in the Medicare Electronic Health Record (EHR) Incentive Program to meet the clinical quality measure reporting requirement of the EHR Incentive Program for payment year 2012 by participating in the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot. Finally, we are making changes to the rules governing the whole hospital and rural provider exceptions to the physician self-referral prohibition for expansion of facility capacity and changes to provider agreement regulations on patient notification requirements.     

VA payment for non-VA public or private hospital care and non-VA physician services that are associated with either outpatient or inpatient care. Department of Veterans Affairs. Final rule

This document amends our medical regulations concerning VA payment for non-VA public or private hospital care provided to eligible VA beneficiaries. This document also amends our medical regulations concerning VA payment for non-VA physician services that are associated with either outpatient or inpatient care provided to eligible VA beneficiaries at non-VA facilities. With certain exceptions, these payments have been based on Medicare methodology. Sometimes VA can negotiate contracts with hospitals or physicians or with their agents to reduce the payment amounts. This document amends these regulations to allow VA to make lower payments based on such negotiations.     

Medicare and Medicaid programs; requirements for physician incentive plans in prepaid health care organizations--HCFA. Final rule

This final rule amends the regulations established by a March 27, 1996, final rule with comment period. The regulations govern physician incentive plans operated by Federally-qualified health maintenance organizations and competitive medical plans contracting with the Medicare program, and certain health maintenance organizations and health insuring organizations contracting with the Medicaid program. As explained in the March 27 rule, the provisions of this final rule will also have an effect on certain entities subject to the physician referral rules in section 1877 of the Social Security Act.     

Physician fee schedule update for calendar year 1992 and physician performance standard rates of increase for federal fiscal year 1992--HCFA. Notice

This notice announces the calendar year 1992 update to the Medicare physician fee schedule and the Federal fiscal year 1992 performance standard rates of increase for expenditures and volume of physician services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1848 (d) and (f) respectively of the Social Security Act. The fee schedule update for calendar year 1992 is 1.9 percent. The physician performance standard rates of increase for Federal fiscal year 1992 are 10.0 percent for all physician services, 6.5 percent for surgical services, and 11.2 percent for nonsurgical services.     

Medicare program; physician fee schedule conversion factor for calendar year 1998 and sustainable growth rate for fiscal year 1998--HCFA. Final notice

This final notice announces the calendar year 1998 Medicare physician fee schedule conversion factor and the fiscal year 1998 sustainable growth rate for expenditures for physicians' services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1846(d) and (f), respectively, of the Social Security Act. The 1998 Medicare physician fee schedule conversion factor is $36,6873. The sustainable growth rate for fiscal year 1998 is 1.5 percent.     

Physician agreements to control medical prepayment plans: Federal Trade Commission. Adoption and publication of enforcement policy with respect to physician agreements to control medical prepayment plans

The Federal Trade Commission has adopted, and is publishing with this notice, a statement of enforcement policy with respect to physician agreements to control medical prepayment plans. The statement sets forth the general approach the Commission intends to use in its case-by-case enforcement program for evaluating physician agreements to form, operate, or control such plans and for evaluating the practices of plans that are controlled by a group of physicians.     

Federal employees health benefits program: limitation on physician charges and FEHB Program payments--Office of Personnel Management. Final rule

The Office of Personnel Management (OPM) is making final its interim regulation that amends current Federal Employees Health Benefits (FEHB) Program regulations. The final regulation requires that the charges and FEHB fee-for-service plans' benefit payments for certain physician services furnished to retired enrolled individuals do not exceed the limits on charges and payments established under the Medicare fee schedule for physician services.     

Physician performance standard rates of increase for federal fiscal year 1993 and physician fee schedule update for calendar year 1993--HCFA. Final notice with comment period

This notice announces the calendar year (CY) 1993 updates to the Medicare physician fee schedule and the Federal fiscal year (FY) 1993 performance standard rates of increase for expenditures and volume of physician services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1848(d) and (f), respectively, of the Social Security Act. It also sets forth an "initial" procedure-specific list of surgical and nonsurgical services to be used in applying the CY 1993 updates. These surgical and nonsurgical designations are subject to public comment. The physician performance standard rates of increase for Federal FY 1993 are 10.0 percent for all physician services, 8.4 percent for surgical services, and 10.8 percent for nonsurgical services. The fee schedule update for CY 1993 is 3.1 percent for surgical services and 0.8 percent for nonsurgical services.