Medicare Reimbursement – What’s the Latest?

Even with the continued political debate over the economics of the Affordable Care Act (ACA), there remains an even more dominating concern. Great concern remains for the actual viability of the overall Act as it applies to providing access to quality care to all US citizens; more specifically, the continued debate over Medicare reimbursement rates.

The mandate to ensure the availability to quality care while also containing and reducing the cost of healthcare in the United States remains an illusion to those entities tasked with this accomplishment. Nevertheless, since the passage of the ACA, there have been both macro and micro level changes within the industry specific to Medicare reimbursements.

Primary macro-level changes that have affected the healthcare delivery system can be noted in cost containment reforms to reduce Medicare and Medicaid spending through restructuring payment reimbursements. This has led to a surge in the implementation of Accountable Care Organizations (ACOs) and the Patient Centered Care Models. It is believed that ACOs are the greatest hope for the much needed and desired delivery system reform.

Operational changes affected by administrative simplification initiatives have taken a critical role in the fiscal solvency, directly affecting the revenue streams for providers and clinicians. Many are facing long and unexplained delays in reimbursements for their clients who are Medicare beneficiaries. The implementation of the HIPAA Version 5010’s deadline initially set for January 1, 2012, has come and gone, leaving practices that were unsuccessful in fully implementing the change faced with extreme delays in reimbursements. The Centers for Medicare and Medicaid Services (CMS) provided a PDF updated document addressing some of the concerns linked to the delayed reimbursements on March 2, 2012. The implementation deadline was then pushed to June of 2012. News on the front indicates that CMS has initiated a program with Emdeon to research the viability of implementing the HIPAA Transaction Version 6020.

Another area of great concern within the healthcare community is the implementation of the ICD-10 codes, along with the consistent HIPAA transactions updates. The push for greater access to information by creating wide-spread HIT systems has created a lack of cohesion within transferring systems. Looming implementation deadlines add to an already stressful environment for practicing clinicians who are struggling financially as a result of the delayed reimbursements from Medicare.

In February 2013, with CMS struggling to overcome a growing level of negative response from practicing clinicians regarding the overall Medicare program, the agency announced continued implementation changes provided through the ACA. These efforts include a proposal to update the 2014 rate-book to mirror the most current Fee-For-Service (FFS) costs, alignment restructuring changes of Medicare Advantage (MA) benchmarks with Medicare FFS costs, and basing some of the MA payment on the quality of the plan. In addition, CMS has proposed a 1.5% increase above the 2013 MA plan payment for 2014, resulting in a 4.91% total adjustment.

Most likely, the continued efforts by health care professionals and organizations to express the ongoing discontent among clinicians regarding the overall state of the Medicare program, served as a catalyst for CMS’ 2013 legislative proposals, which included much needed provider payment incentives. With approximately 92% of Medicare beneficiaries enrolled in the voluntary Medicare Part B program, this should relate to a greater volume of pay-outs for provider incentives in effecting higher levels of quality care. As Medicare Part B assists in covering mental health services primarily provided outside of a hospital setting, this translates into greater opportunity for mental health clinicians who enroll as Medicare providers to offer their services.

As the political debate continues over the ACA, many practicing clinicians remain focused on issues regarding the Medicare program. CMS recognizes the need to ensure cooperation within the health care industry to ensure greater access to quality care for all US citizens as mandated under the ACA. As such, this should continue to effect both macro and micro level changes within the health care industry specific to Medicare reimbursements.


Leibenluft RF (2011). ACOs and the enforcement of fraud, abuse, and antitrust laws. The New England journal of medicine, 364 (2), 99-101 PMID: 21175308

U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2013, February 15). Details for Rate Year: 2014.

U.S. Department of Health and Human Services, Centers for Medicare and
Medicaid Services, (2012, March 4). Medicare Advantage Rates and Statistics.

U.S. Department of Health and Human Services, Centers for Medicare and
Medicaid Services, (2012, June). Medicare and Your Mental Health Benefits.

U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2012, March 7). Version 5010 and D.0 & 3.0.

U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2013). Fiscal 2013 Budget in Brief: Strengthening Health and Opportunity for All Americans.

Image via S_L / Shutterstock.

Brenda Walker, MA

Brenda Walker, MA, holds a Master of Arts Degree in Health Care Administration from Ashford University, a Bachelor of Science Degree in Health Care Management from Anthem College, and an Associates in Applied Science, priority focus in Limited Scope X-Ray. She had over 10 years of experience and a member of the National Association of Independent Writers and Editors. Her primary focus, recently, has been on the continued roll-out of the ACA, Medicare, and Strategic Planning and Implementation for small and private health care entities.
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