Will Your CMS Reimbursements Increase in 2018?

Read time: 5 minutes

If your practice is in one of the 52 localities eligible for geographic adjustment, you could start seeing more from CMS in 2018.

As part of the Bipartisan Budget Act of 2018, healthcare practices in 52 localities throughout the U.S. will see more in reimbursements from the Centers for Medicare & Medicaid Services (CMS). Why? Because the GPCI floor for localities with a wRVU of less than 1.00 was extended. That sounds like a big deal, but what is GPCI?

 

GPCI is an abbreviation for geographic practice cost index. It’s a way to calculate what a practice will be reimbursed for procedures under the resource-based relative value scale or RBRVS methodology.

 

Because practices everywhere use the same wRVU, practice expense, malpractice, and conversion factor values, CMS uses a GPCI multiplier to account for higher and lower cost areas. It’s like comparing the cost of renting an apartment in San Francisco versus rural Oklahoma. The calculation for reimbursement looks something like this:

 

((wRVU*wRVUGPCI)+(PE*PEGPCI)+(MP*MPGPCI))*Conversion Factor = Reimbursement

 

Here’s a real-world example for 99213, a common evaluation and management code:

 

((0.97*1.00)+(1.02*1.00)+(.07*1.00)*35.9996) = 74.16

 

The 1.00 in the above formula represents the national cost index. States like Oklahoma with a GPCI of 0.96 would be reimbursed at a rate lower than the national payment floor (because it has a lower than average cost of living). Now, thanks to the Bipartisan Budget Act, states with a GPCI under 1.00 wRVU will get a bump up to the national payment floor of 1.00.

 

The best part? Medicare Administrative Contractors (MACs) will reprocess these claims automatically, and will pay the higher rate through December of 2019.

 

But don’t leave anything to chance. MACs will be reprocessing hundreds of thousands of claims, so make sure your practice is tracking reimbursement and has a system in place for accurately modeling what you should be reimbursed. Verify that your fee schedules represent the update in CMS reimbursement, and if you have Medicare Advantage plans that reference the CMS fee schedule, make sure those get updated too.

 

To learn how Rivet can help you track reimbursement and model what you should be reimbursed, request a demo today.