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Reimbursement Updates & Reminders


2% Medicare Payment Adjustment (Sequester) Suspended Through End of 2021

Last week Congress passed legislation that was then signed by President Biden that extends relief from the 2% Medicare sequestration cuts through the end of this year. The OOS, AAO, OSMA, AMA and most national specialty societies advocated for these changes that were initially extended through March 31 and now through December 31.

Ohio Medicaid Announces Managed Care Organization (MCO) Contracts

The Ohio Department of Medicaid (ODM) has selected six companies as the recipiens of the next managed care organization (MCO) contracts. The contracts are scheduled to start in January 2022.

The six companies include existing MCOs and new entrants to the market. The selected companies include:

  • AmeriHealth Caritas Ohio, Inc.
  • Anthem Blue Cross and Blue Shield
  • CareSource Ohio, Inc.
  • Humana Health Plan of Ohio, Inc.
  • Molina Healthcare of Ohio, Inc.
  • UnitedHealthcare Community Plan of Ohio, Inc.

A decision regarding Buckeye Community Health Plan was deferred, and the other current MCO, Paramount Healthcare, was not selected.

The OOS anticipates ODM will be releasing more details about implementation of the new contracts throughout the summer and we will pass along information as we obtain it.

Optum Revises Policy that Raised Fees on Ophthalmology Practices

The OOS worked with AAO, OSMA, AMA and other national specialty societies pushing back to revise recent changes to Optum Pay that would have charged fees to practices to access basic claim information.The results of these advocacy efforts led Optum to announce that they will allow practices to continue to access basic claim information with no fees. And if a practice had already signed up for the premium plan that charged fees—they can now cancel that upgrade.

View the policy announcement & more details here:

Repayment of Medicare Accelerated and Advance Payments Started on March 30

If you applied for and received accelerated/advanced payments from Medicare at this time last year, CMS recently issued a reminder and clarification on payback terms for your practice.

Under the Continuing Appropriations Act, 2021 and Other Extensions Act, repayment will now begin one year from the issuance date of each provider or supplier’s accelerated or advance payment.  After that first year, Medicare will automatically recoup 25 percent of Medicare payments otherwise owed to the provider or supplier for eleven months.  At the end of the eleven-month period, recoupment will increase to 50 percent for another six months.  If the provider or supplier is unable to repay the total amount of the accelerated or advance payment during this time-period (a total of 29 months), CMS will issue demand letters requiring repayment of any outstanding balance, subject to an interest rate of four percent consistent with the Continuing Appropriations Act, 2021.

Full release and information:

Anthem Downcoding E&M Codes

The OOS has heard from several practices across the state regarding Anthem’s new policy to automatically downcode certain ophthalmologists claims based on evaluation of past claims compared to peer groups. The OOS is working with the OSMA (as many different specialties have been impacted by this new policy) to review a variety of approaches to advocate against these changes at both the state and national levels including the Ohio Department of Insurance, Ohio Department of Medicaid and CMS. We will keep members updated on our progress.



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