PPACA Summary

President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law on March 23, 2010. Although there were no provisions made regarding the Sustainable Growth Rate (the Congress plans to address this later in the year), we have summarized some key aspects of the law that may affect your practices immediately and in the future.

Administrative Simplification

The law amends the Health Insurance Portability and Accountability Act (HIPAA)’s administrative simplification provision to ensure uniform standards are implemented for health insurance claims processing and requires that standards are created for electronic funds transfers.

Value Based Payment Modifier under the Medicare Physician Fee Schedule (MPFS)

Beginning on January 1, 2010, specific physicians selected by the Secretary of the Department of Health and Human Services (HHS) will be subject to a budget neutral adjustment to the MPFS based on the quality of care they provide to patients relative to costs incurred. Effective from January 1, 2015, all physicians will be subject to this payment adjustment.

National Pilot Program on Payment Bundling

By January 1, 2013 the Secretary of the HHS is required to establish a pilot program to test and assess alternative Medicare payment methods during an episode of care provided around a hospitalization that will improve coordination, quality, and efficiency of health care services. The program will last for 5 years.

Extension of the work Geographic Practice Cost Index (GPCI)

The law extends the geographic adjustment floor (expired in 2009) through calendar year (CY) 2010.

Mis-valued codes under the physician fee schedule

Requires the HHS Secretary periodically to use specified criteria to identify potentially mis-valued codes and to review and make appropriate budget neutral adjustments in their assigned relative value units, including potentially consolidating individual services into bundled codes for payment. The law also requires the Secretary to establish a process to validate relative value units, including a sampling of codes meeting the specified criteria for being potentially mis-valued.

Establishment of the Independent Medicare Advisory Board (IMAB)

The IMAB will make recommendations to the Congress that will extend Medicare solvency, decrease the rate of per capita Medicare spending, and improve the quality of care. The IMAB will also make recommendations annually on ways to improve the quality and control the rate of cost growth in the private sector.

Filing Requirements for Medicare Fee-For-Service (FFS) Claims

Under the new law, claims for services furnished on or after January 1, 2010, must be filed within one calendar year after the date of service (DOS). Also, the legislation mandates that claims for services furnished before January 1, 2010, must be filed no later than December 31, 2010. Claims with dates of service before October 1, 2009, must follow the pre-PPACA timely filing rules (filed within 36 months after the DOS). Claims with dates of service October 1, 2009, through December 31, 2009, must be submitted by December 31, 2010. The HHS Secretary may make certain exceptions to the one-year filing deadline. Proposals for these exceptions will be specified in future proposed rulemaking.

Modification of equipment utilization factor for advanced imaging services

The law increases the utilization rate assumption for expensive diagnostic imaging equipment from 50 percent to 75 percent for 2011 and subsequent years.

Requirement for Physicians who order items or services to be enrolled in Medicare

Effective July 1, 2010, only physicians who are enrolled in Medicare will be allowed to order Medicare covered home health (HH) services and durable medical equipment (DME).

Requirements for physicians to provide documentation on referrals to programs at high risk or waste and abuse

Effective January 1, 2010, the HHS Secretary may withdraw from Medicare (for up to one year for each act) physicians and other providers who fail to maintain and, upon request, provide access to documentation relating to written orders for DME and HH and for referrals for other items and services ordered by these physicians under the Medicare program.

Expansion of the Recovery Audit Contractor (RAC) program

The law extends the Recovery Audit Contractor (RAC) program to Medicare Parts C and D and Medicaid. RACs must ensure that each Medicare Advantage organization and Part D plan has an anti-fraud plan.

Please contact us at healthpolicy@entnet.org if you have questions.

Posted April 9, 2010


Find an ENT

More Options

Business of Medicine Workshops

Practice Management Workshops

Workshops held in cities nationwide will help otolaryngologists, their staff, and other healthcare professionals code correctly, learn risk reduction strategies, and organize business systems.

Learn More Learn more