November 1, 2006  Legislation


Provider Medicare Enrollment


California has told Kaiser to reinstate the coverage of a patient was illegally cancelled.  She had large kidney stones and needed urgent treatment.  She also had individual coverage after group coverage and then COBRA.  Kaiser also threatened to report her for fraud and billed her for $13,000 in medical costs.  Kaiser had claimed the patient had not disclosed an appointment with Kaiser for arm pain.  Kaiser had a record of the visit and had paid for the treatment and medication.  After being terminated from Kaiser she appealed and was denied and then joined a class action suit which was settled.  She was in the process of arbitration when the State's action occurred.  

The Democrats are confident that they will get the majority in Congress after this upcoming election.  They are starting their agenda on healthcare now.  This include having the government to negotiate directly with pharmaceutical companies for Medicare lower prices.  The private companies already get below market price for Medicare but the Democrats think that it could be lower, low enough so they could provide coverage through the "doughnut hole". Both Democrats and some Republicans are for stem cell research.  The Democrats have said they will probably have to raise taxes to pay for their healthcare proposals, especially coverage for the uninsured.  The Democrats agenda also includes a huge increase in funding for the NIH. 

CMS has proposed a new Physician Fee Schedule that would restrict physicians from billing for all components of a test and then paying a radiologist or pathologist a set fee and pocketing the difference.  This is being done in some offices with MRIs or small labs using the in-office exception.  This rule may be final in the next several months.  Also all imaging done in the office or at independent imaging centers will be cut 5% starting the first of the year. 

Starting January 1, hospitals and physicians will have to take Medicaid rates if they have an emergency patient and they have no contract.  This is in the This is in the 2005 Deficit Reduction Act. Some states already have this in place under state law.  

The People's Republic of Massachusetts  new healthcare insurance reform has been changed.  There will be less forms required for business to fill out to show their employees have other health insurance.  The employers will also get  a six month extension in the mandate to offer insurance paid with pre-tax funds.  After July 1, employers will have to pay the employees for all medical expenses if the employee uses the free system.  The employers must pay a $5000 a week fine if they are late in filing the required paperwork on uncovered employees.  The employer would need at least $50,000 in medical bills before that kicked in.  

A new set of voluntary (for now) rules has been put in place for all hospitals to reduce errors.  They include notifying patients and families promptly when an error has occurred.  They must adopt evidence based guidelines to reduce errors during hand-offs.  The full panoply of new practices will be released by the National Quality Forum.  The Joint acknowledges that less than 10% of their accredited hospitals could pass the new standards.  This says alot about the Joint.   

As physicians face a 5% decrease in payments by the feds, the hospitals will get more.  Hospitals get more money per procedure if it is performed as an outpatient.  There will be more procedures paid for if done as an outpatient.  This includes a mandated 3.4% increase in payments. Due to the amount of outpatient procedures performed and the complexity of them, it is expected that the hospitals will get 9.2% more in 2007 en total than they got in 2006.  This new outpatient changes are also tied to the above new inpatient changes.  If people are interested in all the changes they can go to the website at

Pennsylvania has extended the non-payment by high risk specialists into the state insurance fund for another year and a drop by 50% for all the rest.      Top


Provider Medicare Enrollment

Medicare has new rules for enrollment for providers.  If you have any changes you must submit a 855 Report.  If you are a new enrollee you must submit a 855 report.  These reports are lengthy and must be completely accurate.  You must have prior to submitting the 855 your NPI and Electronic Transfer numbers.  The web site for the information is  This 855 must be refiled every five years.  Make sure you are filing the new 2006 855 report.  If you are a solo provider who is incorporated you only need to fill out the 855(i) report.        Top


DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.