George W. Bush’s arrival at the White House has given physicians new hope that a bill easing Medicare mistreatment of physicians will pass Congress this year and be signed by the President. The bill is called the Medicare Education and Regulatory Fairness Act (MERFA). Rep. Shelley Berkley (D-Nev) is the key House sponsor of H.R. 868 (S. 452 in the Senate). At recent hearings in the House health subcommittee, even Rep. Pete Stark (D-Calif), normally an implacable foe of the American Medical Association, admitted that physicians deserve some relief from Medicare nitpicking. He did not endorse the Berkley bill, however.
The bill’s most radical provisions would limit the ability of insurance companies to conduct pre- and postpayment audits of physician billinga cause of great anguish for physicians. Not surprisingly, those provisions will have the most difficult chance of passage. Bob Doherty, a top lobbyist for the American College of Physicians/American Society of Internal Medicine, said the audit provisions are "very reasonable." For example, he explained that Medicare’s current practice is to withhold payment of a physician’s bill, even if it is 100% correct, if that bill is part of a "prepayment" audit during which the insurance carrier randomly selects a predetermined number of claims to examine more closely. MERFA has a provision that would prohibit Medicare from holding up payment "without cause."
Another irritant is Medicare’s practice of examining, as part of a postpayment audit, a physician’s billings for a particular CPT code. A sample of bills is scrutinized, and any errors are extrapolated to the entire year’s billings for that CPT codeand sometimes for past years. MERFA would not allow Medicare to extrapolate the first time a postpayment audit turns up problems.