Physicians Can Expect Retroactive Medicare Payments from CMS

Agency Bends to Pressure from AAFP, Others

February 16, 2011 04:15 pm News Staff

In response to pressure from the AAFP and other physician organizations, CMS has announced that it will reprocess a large number of Medicare fee-for-service claims to account for retroactive Medicare payment increases implemented in 2010.

As reported by AAFP News Now in December, scores of physician organizations, including the AAFP, signed on to a letter to CMS pointing out six provisions in the Patient Protection and Affordable Care Act that called on CMS to reimburse physicians retroactively back to Jan. 1, 2010. The letter also detailed changes made to the final 2010 Medicare physician fee schedule that resulted in money due to physicians.

The organizations requested quick action from CMS to resolve the issue.

Fast forward to Feb. 8, when CMS sent an electronic message to physicians and other Medicare providers explaining the underpayment and assuring physicians that a plan was in place to make sure they receive full payment.

In that message, CMS said it was taking steps to ensure new claims were paid quickly and accurately, even as the agency was beginning to process the retroactive claims.

"CMS will begin to reprocess these claims over the next several weeks," said the agency in its message to physicians. "We expect that this reprocessing effort will take some time and will vary depending upon the claim type, the volume and each individual Medicare claims administration contractor."

Specifics that physicians need to keep in mind include

  • refrain from resubmitting claims because they will be denied as duplicate claims, and that will slow the retroactive adjustment process;
  • do not request adjustments for all claims in question from Medicare claims contractors because, in most cases, contractors will automatically reprocess claims;
  • ask your Medicare contractor to manually adjust or "reopen" any claim that contains services with submitted charges that are lower than the revised 2010 fee schedule amount because those claims cannot be automatically reprocessed at the higher rates; and
  • Medicare is extending its normal one-year time limit for reopening of claims that may need adjustment.

CMS noted that any retroactive amounts due would be included in a physician's next regularly scheduled remittance after the adjustment is made. The agency also reminded physicians and other Medicare providers affected by the retroactive payments about the HHS Office of Inspector General policy( that says providers will not be subject to administrative sanctions if they waive beneficiary cost-sharing amounts attributable to retroactive increases in payment rates that are a result of new federal statutes or regulations.