2013 Increased Claims Reimbursement

Due to recent legislative changes, many providers will see increased claims reimbursement in 2013. increase profits      Below are the details of three areas that will be effected.

  • Increased Medicaid Payments to Primary Care Physicians:

The National Quality Strategy, required by The Affordable Care Act of 2010, is a national plan to improve the delivery of health care services, patient health outcomes, and population health. Three goals are used to guide and assess local, state, and national efforts to improve health and the health care delivery system: better care, healthy people/healthy communities, and affordable care.

Medicaid and CHIP currently provide health coverage to nearly 60 million Americans, including children, pregnant women, parents, seniors and individuals with disabilities. Medicaid payment increases are planned for certain primary care services provided to Medicaid beneficiaries in 2013 and 2014. This is an attempt to draw more primary care providers into the program in order to handle the inevitable increase in demand as enrollment is expected to expand by somewhere between 10-16 million individuals starting at the beginning of 2014.

Reimbursement will be raised to payment rates that match Medicare for specific services provided by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine. The services subject to the increase are evaluation and management services represented by procedure codes in the category designated Evaluation and Management in the Healthcare Common Procedure Coding System and services related to immunization administration for vaccines and toxoids for CPT codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, and 90474.

Higher payments and increased provider participation are key factors in implementing the National Quality Strategy.

  •  Increased Medicare payments to Primary Care Physicians:

The Centers for Medicare & Medicaid Services (CMS) issued a final rule with comment period on November 1, 2012 for Medicare’s payments for physician fees for 2013.  It includes a new policy to pay a patient’s physician or practitioner to coordinate the patient’s care in the 30 days following a hospital or skilled nursing facility stay.  The changes in care coordination payment and other changes in the rule are expected to increase payment to family practitioners by seven percent—and other primary care practitioners between three and five percent—if Congress averts the statutorily required reduction in Medicare’s physician fee schedule.

This new physician fee rule is part of the drive to reward savings and foster collaboration amongst primary care providers.

The final rule with comment period can be viewed at:


The rule will be published on November 16, 2012.  It will take effect January 1, 2013 with a comment period that closes on December 31, 2012.

  • Increased Medicare Payments for Outpatient Hospital Services:

The Centers for Medicare & Medicaid Services (CMS) finalized the Hospital Outpatient Prospective Payment System (OPPS) rule on November 1, 2012, updating Medicare payment policies and rates for hospital outpatient services beginning January 1, 2013.

The final OPPS/ASC rule with comment period affects hospital outpatient departments in more than 4,000 hospitals, including general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute care hospitals, children’s hospitals, and cancer hospitals, and approximately 5,000 Medicare-participating ASCs.

Rates and policies set in the calendar year (CY) 2013 final rule with comment period will increase payment rates for hospital outpatient departments by 1.8 percent. The increase is based on the projected hospital market basket—an inflation rate for goods and services used by hospitals—of 2.6 percent, minus 0.8 percent in statutory reductions, including a 0.7 percent adjustment for economy-wide productivity and a 0.1 percentage point adjustment required by statute.

Total payments to hospitals under the OPPS in CY 2013 will be approximately $48.1 billion.

To view the CY 2013 OPPS and ASC payment system final rule with comment period and changes to the QIO program, please see:  


The rule will be published on November 15, 2012.  It will take effect January 1, 2013 with a comment period that closes on December 31, 2012.