Tufts Health Plan 60-Day Notification
Effective January 1, 2010
Annual Updates to Physician and Hospital Reimbursement

Consistent with past years, Tufts Health Plan will update its physician and hospital fee schedules effective January 1, 2010. Tufts Health Plan will continue to base fees on the Centers for Medicare & Medicaid Services (CMS) fee schedules, adjusted to achieve the contracted level of reimbursement.

For physicians, Tufts Health Plan will diverge from CMS again in 2010 by directing a higher proportion of funds to the fees for vaginal deliveries and a slightly lower proportion of funds to psychiatry visits. In addition, to moderate the impact of the projected reimbursement fluctuations published by CMS in July for 2010, Tufts Health Plan is opting to base reimbursement on a blend of CMS 2009 and 2010 schedules. Drug pricing will remain at the same ASP levels as in 2009.

In Tufts Health Plan’s ongoing efforts to more closely align reimbursement with industry standards, physicians also can expect two important changes to the structure of Tufts Health Plan fees for 2010:

• Tufts Health Plan will replace its non-standard facility fee reduction and office surgery programs by adopting CMS’ differential reimbursement for office- and facility-based services. This change is reflected in the Evaluation and Management, Surgery Professional, and Mental Health and Substance Abuse Outpatient payment policies.
• Also consistent with CMS physician reimbursement, Tufts Health Plan will adjudicate and reimburse separate technical fees for selected procedures.

The specifics for fee schedule changes, the applicable 2010 fee schedule, and all modifications to our non-reimbursable procedures list will be distributed to hospitals and IPA leadership in November 2009.

Independent physicians who have questions about fee schedule changes should contact Tufts Health Plan’s Network Contracting Department at 888-880-8699, ext. 2169.

To ensure appropriate reimbursement levels, physicians are reminded not to bill, on the same claim, for services with dates that cross calendar years.

Please remember to consult tuftshealthplan.com/providers for information regarding changes to non-reimbursable codes, payment policies and edits that could also affect reimbursement.

November 1, 2009