[MMA News Now, Jan. 17, 2013] The Minnesota Department of Human Services (DHS) late last week announced its plans for implementing the Affordable Care Act (ACA) provision increasing Medicaid payment rates for specified services provided by primary care physicians for services delivered Jan. 1, 2013, through Dec. 31, 2014. 

Physician attestation of eligibility is required; the MMA urges physicians to complete this by April 1, 2013. Services eligible for the enhanced payment include Evaluation and Management (E&M) codes 99201-99499 and vaccine administration codes (90460-90461 and 90471-90474).

To be eligible for the enhanced reimbursement, physicians must first self-attest that they practice in family, general internal or pediatric medicine. As part of that attestation they must specify that they either are Board certified in one of those eligible specialties or subspecialties and/or that 60 percent of their Medicaid claims for the prior year were for the E&M codes eligible for enhanced payment. Both fee for service and managed care claims are included in the calculation of the 60 percent criteria.

For physicians newly enrolling in Medical Assistance, 60 percent of all billings in the previous month must have been for the covered services listed above.

DHS has developed an attestation form that eligible physicians must complete and submit by fax to the department. Submission of the attestation form by April 1, 2013 ensures that eligible services provided since Jan. 1, 2013, will receive the enhanced rates. For attestation forms submitted on or after April 1, 2013, the enhanced rates will only apply to services effective the first of the month in which the form is received by DHS. 

The enhanced rate paid will be the higher of a) the Medicare Physician Fee Schedule (MPFS) rate in effect for the year in which the service was performed (either the 2013 or 2014 Medicare Physician Fee Schedule rate) or b) the rate using the Relative Value Unit for the calendar year in which the service was performed, multiplied by the 2009 Medicare conversion factor. If the physician’s submitted charge is lower than either of the applicable Medicare rates, the physician’s submitted charge will be paid. 

DHS will perform reviews on a statistically valid sample of self-attested physicians to determine that the eligibility criteria are being met. Services retroactively found ineligible for the enhanced payment will be subject to recoupment of the overpaid amount.

Final guidance for Medicaid managed care compliance with the enhance payment rates has not yet been issued by DHS, but is expected soon. As details are released, the MMA will provide its members with details.