News in brief - Jan. 20, 2003

Medicare cut to hit claims processed after March 1 - Medicare now covers anticoagulation monitoring - Justice Dept. orders N.C. IPO to dissolve

Medicare cut to hit claims processed after March 1

Although the 4.4% cut in Medicare payment rates has been delayed until March 1, the Centers for Medicare & Medicaid Services has instructed carriers to use 2002 rates only for claims processed by that date. Claims for services provided in January or February but not processed before March 1 will be paid at 2003 rates, the agency said in a program memo.

CMS also extended until Feb. 28 the deadline for doctors to make Medicare participation changes. Participation agreements, however, will be effective Jan. 1, and physicians must bill in accordance with their decision once it is submitted to the carrier.

Until a participation decision is available, carriers will use the physician's 2002 participation status to process 2003 claims. Participating physicians agree to accept the Medicare rate for services. Nonparticipating physicians receive lower payments from Medicare but can bill beneficiaries more.

Claims for services with new codes in 2003 will be suspended by Medicare carriers until March. Physicians are urged not to submit those claims until that time.

But CMS instructed carriers to pay interest on clean claims that are suspended.

Medicare now covers anticoagulation monitoring

The Centers for Medicare & Medicaid Services announced Medicare coverage for home prothrombin time international normalized ratio monitoring for anticoagulation management. Use of the ratio allows physicians to determine the level of anticoagulation in a patient independent of the laboratory reagents used.

For services provided after July 1, 2002, Medicare will pay for the use of the monitoring for patients with mechanical heart valves and who are on warfarin. Because porcine valves are not covered by Medicare, monitoring of patients with these valves is not covered. To be eligible, patients must have undergone three months of anticoagulation therapy, patients must participate in an education program on anticoagulation management and the use of the device, and the self-testing must be limited to once a week.

Justice Dept. orders N.C. IPO to dissolve

The U.S. Dept. of Justice says an Asheville, N.C.-based physician's organization -- Mountain Health Care -- will have to disband because it limited competition among physicians. The Justice Dept. in December 2002 filed a lawsuit and a proposed consent decree that would resolve the lawsuit in the U.S. District Court in Western North Carolina at the same time.

In its complaint, the Justice Dept. alleged that physicians and physician groups that normally would have competed with one another adopted a uniform price schedule and authorized Mountain Health Care to negotiate with health plans on their behalf. The system led to higher health costs for consumers, Justice said, because Mountain Health Care did not clinically or financially integrate its physicians to create efficiencies that outweighed the alleged anticompetitive actions.