[Provider] Corrected Version: Billing for Hospital-Based Physicians

[Provider Notification]

(You may discard the earlier e-mail.  We apologize for any confusion.)  

 

To:  Hospital CEOs, CFOs and Patient Account Managers

 

From:  Tony Marple, Director of MaineCare, DHHS

 

Re:  Billing for Hospital-Based Physicians

 

MaineCare rules have changed in response to the Maine supplemental
budget, PL1 (2009).   The supplemental budget states: 

 

Sec. V-1. Hospital-based physician reimbursement; rules. Effective
February 1, 2009, the Department of Health and Human Services shall
amend the rules regarding reimbursement under the MaineCare program for
hospital-based physician services to provide for reimbursement at a rate
as close to 70% of the Medicare reimbursement rate as the department
determines can be funded with the resources used for physician
reimbursement in the Medical Care - Payments to Providers General Fund
account, as adjusted by this Act. Rules adopted pursuant to this section
are routine technical rules as defined in the Maine Revised Statutes,
Title 5, chapter 375, subchapter 2-A. 

 

Accordingly, certain hospital outpatient services are now required to be
paid on a fee schedule rather than on a cost basis.  Outpatient services
include office and clinic-based services, ambulatory surgery, ambulatory
procedures and diagnostic readings.   Services in the emergency room are
not outpatient for this purpose.  

 

The rule affects all physicians, physician assistants, nurse
practitioners, and nurse anesthetists providing services billed by the
hospital.  It applies whether those professionals are hospital employees
or contract workers.  

 

To comply with the rule, you must proceed with the following steps.

 

1.	Enroll as MaineCare servicing providers all physicians,
physician assistants, nurse practitioners, and nurse anesthetists who
provide any outpatient services. Emergency room physicians are excluded
from this requirement.  
2.	Bill MaineCare for the outpatient services of those
professionals on professional (CMS1500) rather than institutional
(UB92/UB04) claim forms. 
3.	Enroll these professionals as soon as possible and no later than
July 1, 2009.   You may begin to submit professional CMS1500 claims as
soon as the professionals have been enrolled.
4.	You must bill for outpatient services for the professions listed
above via professional claims.  Inpatient and emergency department
services of those professionals can be billed on either type of claim
form.   

 

Professional claims, inpatient or outpatient, will be paid via check or
funds transfer at the time of claim adjudication.  Institutional claims
will continue to be paid via PIP payments.  The amount included in the
PIP payments for outpatient physician costs will be decreased to 46.21%
during the last five months of the fiscal year.  This is to convert the
fee table to a percentage of cost for this time period, while allowing
hospitals time to enroll their physicians.  

 

All inpatient and emergency department claims for professional services
will continue to be cost settled, whether submitted via institutional or
professional claims.  Any payments for non-outpatient 1500 bills will be
subtracted from cost settlements.  

 

We recognize the complexity of this change.  If you have questions,
please contact Cheryl Rood at Cheryl.Rood at maine.gov or 287-5735.  

________________________________________________________________

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