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October 2013 Client Newsletter




Patients now have the right to request providers not to bill their insurance.  This change to the law was made in the 2010 HITECH Act and the new 2013 Omnibus regulations have confirmed the rule. This is part of the patient's right, under HIPAA, to "restrict disclosures" to certain parties. The government has made it clear that Medicare is one of the parties, along with private insurances, to whom disclosure may be restricted by the patient if payment is made in full

The patient has the right to request that no insurance claim be filed if
1. The patient requests this in writing (legible and clearly signed!), AND 
2. The patient pays IN FULL for the services rendered that day. 
Note, however, that if the provider is audited by Medicare, there would have to be disclosure then. 

These new rules were effective March 26, 2013 with compliance required by September 23, 2013.


The Internal Revenue Service (IRS) released a final rule detailing penalties mandated by the Affordable Care Act (ACA) for certain individuals who don't have health insurance. Penalties begin in 2014 and will be the greater of $95 or one percent of household income, with these amounts set to increase in future years. There will be exemptions from penalties in certain circumstances such as being uninsured for fewer than three months, having a low income, objecting to coverage for religious reasons or experiencing hardship.  Individuals who would qualify for Medicaid coverage through the ACA Medicaid expansion, but who live in states that choose not to expand Medicaid, will also be exempt from the penalties.  We believe the penalty is so low that it will be ineffective in convincing people to buy insurance!

Those subject to the fine will have to pay it when they file their 2014 taxes. Beginning Oct. 1, those without coverage can purchase coverage through the new ACA insurance exchanges. To obtain more information on ACA exchange coverage, visit the CMS webpage. 

G0179 & G0180

These codes may not be billed to Medicare within 60 days of each other or themselves.  Medicare will deny due to frequency.  

2012 PQRS and eRx feedback reports now available

2012 Physician Quality Reporting System (PQRS) and E-Prescribing Program (eRx) feedback reports are now available and must be requested through the CMS Communication Support Page. Here you can create a National Provider Identifier (NPI)-level feedback report request. The report will then be emailed to the address specified in approximately 2-4 weeks, according to CMS. Taxpayer Identification Number (TIN)-level reports are also available via the CMS QualityNet website. TIN-level reports also require an IACS account.

Group practices who participated in the Group Practice Reporting Option (GPRO) may access PQRS feedback via the 2012 Quality and Resource Use Reports (QRURs), which will be made available on September 16. An informal review may be requested if a physician or group practice did not earn the 2012 PQRS incentive payment and believe that an incentive payment was earned, or if they consider the payment amount to be incorrect. To submit a review request, visit the Communication Support Page and select the "Create an Informal Review Request" link. Requests will be accepted beginning Nov. 1, 2013 through Feb. 28, 2014.

Medicare Comparative Billing Report

At our HBMA conference in September, a presenter was asked about the Medicare Comparative Billing Report which are sent to some providers.  The presenter indicated that it is informative, BUT it is a warning shot, so to speak, from Medicare. It means the provider is a significant statistical outlier on a specific billing metric - only outliers receive the reports.

While it may be perfectly legitimate and defensible, it should be investigated promptly to ensure there is not a problem with the code utilization that is generating the notice.  For example, the reports have looked at E/M utilization but other specialties are included with multiple code comparisons which are not comparing apples-to-apples.  In those cases it will be important to reply to Medicare to make sure they understand and do not decide to perform a full chart audit which could be very time-consuming and expensive.

2013 Client Newsletter Archive