The Consolidated Appropriations Act – What You Should Know

On December 28, 2020, Congress passed a new spending bill, The Consolidated Appropriations Act of 2021, signed by President Trump, to reduce the cuts imposed by the Medicare Physicians Fee Schedule for 2021. The Act also provides new information on the temporary suspension of Medicare sequestration, surprise billing, and three-year delay of HCPCS add-on code G2211. 

Increase in Conversion Factor and Delay of Payment for HCPCS add-on code G2211  

  • Section 1010 of the Act states that for 2021 only, Medicare shall increase physician fee schedules by 3.75% (this is after considering the 11% reduction in the conversion factor).
  • In 2022, the 3.75% increase will end, and the $20 million budget neutrality number will be based on the conversion factors prior to the 3.75% raise.
  • Initially, a key reason for the conversion factor dropping almost 11% is the introduction of a new Medicare E/M code, G2211, which would increase physician reimbursement dramatically. With Congress’ decision to block the implementation of G2211 until 2024, industry experts have estimated the G2211 block along with a 3.75% conversion factor will have the combined effect of increasing the conversion factor by 7%, thereby offsetting the projected 11% loss in conversion factor rates to only 4%, according to David Vaughn[1].

Extension of Temporary Suspension of Medicare Sequestration

  • The suspension of the Medicare sequestration penalty is extended through March 31, 2021.

No Surprises Act

  • Patients are only required to pay in-network cost-sharing for any out-of-network (“OON”) emergency care.
  • Providers such as anesthesiologists, radiologists, ER docs, and pathologists cannot balance bill patients when services are provided at an in-network facility (even if the docs themselves are out of network).
  • For payment disputes between payors and OoN providers, the legislation provides a 30-day open negotiation period. If an agreement is not reached, access to a binding arbitration process will commence, which is also known as Independent Dispute Resolution (“IDR”).
  • By January 1, 2022, all providers and facilities must have a one-page notice on their website regarding federal and state prohibitions on balance billing and how to contact state and federal agencies if the patient believes the provider has violated those rules.

Key note: If the facility is participating and the provider is OoN, and the provider is not hospital-based, and the service is not an emergency; the OoN provider can balance bill the patient if the following notice and consent requirements are met:

  • The patient must sign the consent and receive a signed copy of the consent.
  • If the facility participates, but the provider does not, the consent must give a list of any participating providers at the facility who are able to provide in-network services and the notice must state that the patient may be referred to that provider.
  • An OoN provider or facility must provide the patient 72 hours before the services are to be rendered a written notice (paper or electronic) which states the following:
    • The provider is nonparticipating.
    • Provide the patient with the estimated cost of the service.
    • States that the estimate is not a contract.
    • Contains information as to whether prior authorization is required or other care management limitations apply.
    • States that consent to receive the services is optional and the patient can receive care with a participating provider or facility.
    • This consent is provided in the 15 most common languages in the geographic region of the applicable facility.
  • The consent must contain the following:
    • Acknowledgment that the patient was provided written notice.
    • Proof the patient was informed that the payment of OoN charges may not accrue toward meeting the payor’s cost-sharing provisions, including in-network deductibles, and that the patient was provided an opportunity to receive the notice either in paper or via electronic copy as selected by the patient.
    • The date on which the patient received the consent and the date on which the patient signed the consent.
    • The consent must stay on record for 7 years.

[1] David Vaughn, Esq., Vaughn and Associates, LLC, Baton Rouge, LA