Medicare / Medi-Cal News

Don't forget to check Medicare patients' eligibility! Traditional Medicare doesn't require much pre-authorization, but Medicare HMO's often do. Medicare could deny your claim if your patient switches to an HMO, then the HMO could deny your claim because you didn't have prior authorization.

When documentation is required to process a Reopening, providers must submit the request as a Written Reopening with a completed "Reopening Form" or through Endeavor. If a request is more complex, beyond clerical errors or omissions, it is appropriate to submit a Redetermination via the "Redetermination Form."

For more Telephone Reopening information, go to






Begin Reporting PQRS Now To Avoid Penalties

The Medicare Physician Quality Reporting System (PQRS) is a reporting program that uses a combination of incentive payments and payment reductions to promote reporting of quality information by eligible professionals. PQRS is mandated by federal legislation. The program provides incentive payments to practices who satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services provided to Medicare beneficiaries. Beginning in 2015, the program will also reduce payments to eligible professionals who do not satisfactorily report quality measures data for 2013 professional services.

To participate in the 2013 PQRS, individual eligible professionals may choose to report information to CMS on individual PQRS quality measures or measures groups (a subset of four or more PQRS measures that have a particular clinical condition or focus in common) using: (1) their Medicare Part B claims, (2) a qualified PQRS registry, (3) a qualified electronic health record (EHR) product or 4) a qualified PQRI data submission vendor.

Individual eligible professionals who meet the criteria for satisfactory submission of PQRS quality measures for services furnished during a 2013 reporting period will qualify to earn an incentive payment equal to 0.5 percent of their total estimated Medicare Part B Physician Fee Schedule allowed charges for covered professional services furnished during 2013.

To avoid the 1.5 percent 2015 PQRS penalty, individual physicians and group practices participating in the PQRS Group Practice Reporting Option will have to satisfactorily report data on quality measures for services provided in 2013. Reporting during the 2013 PQRS program year will be used to determine whether a PQRS payment adjustment applies in 2015. Alternative methods of avoiding the penalty have been made available for the 2013
reporting year.