Private Payer Round-Up, March 2013

In case you missed these — here is aroundup of useful items from health care payment plans’ newsletters and updates, compiled by TMA’s reimbursement specialists.

If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems.

If you have questions about billing and coding or payer policies, contact the specialists at for help, or call TMA Knowledge Center at (800) 880-7955. TMA members can use the to help resolve insurance-related problems.

Medicare Advantage Physicians, Staff Must Complete Training

If you are a physician contracted with a Medicare Advantage Plan (MAP), you are obligated to complete certain training related to fraud and abuse.

The Centers for Medicare & Medicaid Services (CMS) requires MAPs to provide their contracted physicians the free training upon contract and annually. Office staff with access to the Medicare patients’ information have to receive the training as well.

MAPs notify physicians of the training requirements through direct mailings, newsletters, or announcements on their web sites. Once you’ve completed the training, you’ll need to submit an online acknowledgement according to the payer’s instructions. The following training is required: 

  • Fraud, waste, and abuse training — Physicians enrolled in Medicare Part B and their staff are deemed to have met the fraud, waste, and abuse training requirement. CMS also offers a web-based training course, and some MAPs also offer their own webinars or accept training from other sources that meet CMS requirements.
  • General compliance training — Each MAP has to create a compliance plan and communicate it to contracted physicians and their staff, for example, through distribution of the MAP’s standards of conduct and/or compliance policies and procedures.
  • Special Needs Plan training.

Find more information here:

If you have questions, contact the CMS Parts C & D FWA Training at FWATraining[at]cms[dot]hhs[dot]gov.


Sequestration reduction — Medicare will cut physician payments for fee-for-service claims with dates of service on or after April 1 by 2 percent  (PDF), due to across-the-board federal spending reductions required by the federal budget sequestration that took effect March 1.

Earlier on its website, Humana said:

We continue to monitor the potential for reductions to Medicare reimbursement. In the event the reductions are imposed by CMS, Humana will implement the sequestration reduction to network and non-network provider payments in the same manner. All non-network providers and network providers who are reimbursed using a fee schedule based off the Medicare payment system or Medicare allowed amount (e.g. RBRVS, DRG, etc.) will have the same sequestration reduction applied in the same manner as CMS. This reduction will become effective upon the date CMS implements it and will apply to all Medicare Advantage plans.

Watch the Humana’s what’s new page of website for updates.

Claims policies and code edits — Humana recently posted updates to its facility and professional claims policies, as well as its claim code-editing logic. View details regarding these and past changes. If you have questions, call (800) 4HUMANA ([800] 448-6262), Monday through Friday, 8 am to 6 pm local time.

Routine physical exams for Medicare Advantage members — Humana Medicare Advantage members are covered for a routine physical by a single physician once per 365 days at no cost (as long as applicable in-network requirements are met).

A routine physical is not the same as the “Welcome to Medicare” exam for Medicare Advantage members. The “Welcome to Medicare” exam is allowed once per lifetime within the first 12 months of Medicare Part B enrollment. The routine physical exam is allowed once in addition to the “Welcome to Medicare” exam during the first 12 months of Medicare Part B enrollment, and then once per 365 days in the years following the “Welcome to Medicare” physical.

This routine physical includes the following components:

  • Review of medical history and a physical examination to identify risk status and to manage any interventions needed;
  • Counseling on diet, exercise, substance abuse and injury prevention;
  • Blood pressure check every two years after age 21; and
  • At the physician’s discretion, recording of height and weight, and vision and hearing screening.

Use CPT codes 99381-99387 for new patient preventive medicine visits. Use CPT codes 99391-99397 for established patient visits.

Source: Humana’s Your Practice, February 2013

Published March 26, 2013

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Last Updated On

April 27, 2018