Tag Archives: SGR

More on SGR: What is it?

SGR stands for sustainable growth rate and was enacted as part of the Balanced Budget Act of 1997 as a way to limit growth in provider payments and contain program costs.  The SGR is a complex formula tied to United States economic factors.   Each year, for at least the last 10 years, the SGR resulted in potential cuts to physician fees.  Due to extensive grass-roots efforts, congress has postponed the cuts 16 times.  These cuts do not dissolve once they are postponed; they are cumulative and need to be addressed again each fiscal year or more often.

This year at the 11th hour, congress postponed the SGR cut until March 31st.   If nothing is done, physician fees will be cut across the board by 24% on April 1st.  The only permanent way of eliminating the flawed SGR formula is to change it or repeal it via Medicare law.

For the first time, there is a bill in Congress addressing the flawed fundamental SGR formula.  The “SGR Repeal and Medicare Provider Payment Modernization Act of 2014” (H.R. 4015/S 2000) is currently being hotly discussed in Congress.  It appears that there is bipartisan and bicameral agreement that the SGR formula is flawed and needs to be fixed.  The disagreement is in the area of how to pay for the change.  The bill proposes .5% increase in physician fees over the next 5 years, but in Medicare all increases must be budget neutral, so cuts must be made elsewhere in the system.  Where or how these cuts are made is the focus of debate on both sides of the aisle.

It is likely that the SGR issue will be postponed again at the end of March, in order to give congress more time to work out the “pay for” issue.  The good news is that the flawed SGR formula is finally being addressed.


APAPO (March 2014).  Briefing Materials for Hill Visits.

WPA Advocacy Cabinet

(Post Author:  Dori Ann Bischmann, PhD, Wisconsin Federal Advocacy Coordinator for APA/WPA; WPA Medicare Liaison)


Medicare 2014 Physician Fee Rates for Select Codes in Wisconsin

Select 2014 Wisconsin Medicare fee rates as of January, 1, 2014 are as follows:

90791:   $131.28        (In facility: $127.17)  Initial evaluation

90832:   $63.51           (In facility: $62.82)   Psychotherapy 30 minutes

90834:  $84.22            (In facility: $83.88)    Psychotherapy 45 minutes

90837: $126.14           (in facility: $125.45)  Psychotherapy 60 minutes

96101: $79.35              (in facility: $78.67)   Psychological assessment per hour

96118: $96.85              (in facility: $78.32)  Neuropsychological assessment per hour

96150: $21.20              (in facility: $20.86)    H&B initial evaluation per 15 minute unit

96152:  $19.42             (in facility: $19.08)    H&B individual psychotherapy per 15 minute unit

90785: $14.08               interactive complexity add-on

90839: $131.82             (in facility: $130.79)  Psychotherapy for crises, first 60 minutes

These are the most recent published rates which account for the 3 month postponement of the SGR cut with the slight .5% increase in fees.

The Advocacy Cabinet

(Post Author:  Dori Ann Bischmann, PhD)


Hartman-Stein, P. (2014).  Government health care changes have wins, losses for psychology.  The National Psychologist, 23(1), 6-7.

National Government Service:  http://www.ngsmedicare.com/ngs/portal/ngs medicare/fee schedules downloads part b.


SGR Cut Temporarily Delayed

SGR (sustainable growth rate) is a complex formula tied to the United States economy that determines the rates paid to physicians (including psychologists) under Medicare.  Each year, for at least the last 10 years, the SGR resulted in cuts to physician fees.  Fifteen times congress has postponed the cuts.  These cuts do not dissolve once they are postponed; they become cumulative and need to be addressed again each fiscal year.

As of January 1, 2014, we were due for a 24% SGR cut, but congress delayed the cut for three months to allow more time to consider the options.  For the first time, there are bills in Congress addressing the fundamental SGR formula within Medicare law.  Changing Medicare law is the only permanent way to stop the automatic SGR cuts.

In addition to postponing SGR cuts for three months, congress gave an across the board increase of 0.5% to physician fees.  Psychologists were instrumental in contacting their congress persons asking them to postpone the SGR cuts.  Grass roots efforts really do work.

I’d like to feel excited about the 0.5% increase and 24% SGR postponement, but it is difficult to feel excited when fee cuts occur more often than increases.  We still have the 2% across the board sequestration cut to contend with (starting 1/1/14) and the recent fee cuts to initial evaluations and other codes.  It has been a difficult year with regard to Medicare reimbursement.

Since we have a new diagnostic manual, I’d like to propose a new diagnostic code: Medicare Dysphoric Disorder.  I haven’t yet decided whether it should be classified with the mood disorders or the stress disorders.  If you think you have this disorder, the only cure is to write to your congress persons encouraging them to continue to postpone the SGR cut and develop a permanent fix to the flawed SGR formula.

WPA Advocacy Cabinet

(Post Author:  Dori Ann Bischmann, PhD)





Teaser for New Information to Come Soon

There are so many changes in Healthcare that it has been difficult to keep up!   Starting in January, I will to go through the changes in more depth, but for now here is a summary:

1.  Wisconsin is expected to delay the cancellation of Badger care and HRSP (the WI high risk insurance sharing plan) to March so people can avoid coverage gaps while ACA (Affordable Care Act, e.g. Obamacare) website is fixed.

2.  As of January 1, 2014, Medicare payments for mental health services are on full parity with Medical services.  Medicare pays 80% for all services. Thus there is a 20% copay for all services.

3.  Most psychotherapy codes will have a small increase in Medicare reimbursement due to changes in the work value formula.  90832 does not increase and 90791 is expected to decrease by 15% (national average).

4.  SGR cut is delayed for three months to allow congress more time to figure out an alternative.

5.  No news yet on whether recent budget will impact the expected 2% sequestration cut to physician fees.

6.  The healthcare exchange website, Healthcare.gov, is working better and more people have been able to sign up for insurance policies through the website (including me, yippie!), but there are still technical problems to be worked out.

7.  Dean care insurance will be/is expanding its coverage area east into Waukesha County.  Dean does offer insurance plans on the Healthcare exchange for Waukesha Co residents, but in my opinion they don’t yet have enough providers east of Oconomowoc.

8.  Medicare is changing the rules regarding PQRS.  It is expected that completing 9 PQRS measures on 80% of your Medicare patients will be required for 2014 to avoid penalty in 2016.  Some PQRS claims based measures (what psychologists use) may be retired.  New ways to measure services, such as “value” are being proposed for the next couple of years.

9.  It appears that reporting PQRS measures via a registry is valued above reporting via claims based reporting.  APA is discussing the feasibility of developing a registry for psychologists.  It is my read that in the next couple of years psychologists will not be able to participate in PQRS (but will be able to incur penalties) if we are unable to report via Registry.

10.  The “Physician Compare” website is up and running.  This website will provide data on all physicians (including psychologists) and is available to the public (and insurance companies).  The website is put together by Medicare, but it is a requirement of the ACA.  The only interesting data I see on my listing so far is that I participate in PQRS.  Eventually, the ACA’s goal is to include ratings and other information that will allow the public to determine how an individual physician compares to others in his/her discipline.  Imagine what an insurance company might use this information for…..just saying.

11.  Healthcare changes are occurring rapidly.  These are changes you must know or you will potentially suffer penalties, be left out of insurance panels or other undesired things.  Please, please, please be a member of  your respective provider associations.  It is their job to sort through the volumes of government information and bring the must know info to you. It is impossible to keep up with the changes independently and you can’t afford to wait for pertinent info to trickle down through the grapevine. The changes are occurring too rapidly and they are often quite complex.

12.  While most of these changes start within the Medicare program, they will be applied to all programs in one way or another.  With the ACA, what was once restricted to Medicare, will eventually apply to all insurance plans.

13.  Details to come in January when written policies are available for review.

The WPA Advocacy Cabinet

(post author:  Dori Ann Bischmann, PhD)

Highlights on the Hill

Rain Soaked but Dedicated

Rain Soaked but Dedicated

Despite being soaked to the skin by pouring rain while waiting in security line, the visit to the hill in Washington D.C. was very exciting! We met with staffers in the following congressional offices: Reid Ribble, Gwen Moore, Paul Ryan, Ron Kind, James Sensenbrenner and Tom Petri. We also met with congressman Mark Pocan and his legislative aide. Unfortunately, we were unable to get appointments with our two senators, Ron Johnson and Tammy Baldwin and congressman Sean Duffy.

For the first time, it appears that there is some movement with regard to SGR. Every office was very aware of the SGR issue. Every office appeared to agreed that the SGR formula was a problem and should be permanently fixed. Paul Ryan is addressing Medicare issues at the “macro level” and typically has not voted in support of specific SGR bills in the past. Of the offices that we visited, Gwen Moore was the most supportive of our issues. Gwen is already a cosponsor of the bill including psychologists in the physician definition in Medicare and her aid advised her to become a cosponsor of the bill for including psychologists in the incentives for setting up electronic health records. We were told that there are a couple of bills circulating that pertain to making a permanent SGR fix so that we are not plagued with the SGR cuts every year.

There is so much information to share with you that I can’t possibly share it in one or two blogs. Over the next few weeks, I will be sharing information with regard to PQRS, psychotherapy codes and the agenda items we presented to our legislators.

At this point, I have a request for all of you. It is important for psychologists to develop relationships with our legislators. I am asking you to help me by being willing to talk with your particular legislators and advocating for the issues of interest to psychologists. Legislators appreciate hearing from their own constituents and all of them accept appointments with constituents in their home office. Gwen Moore’s office made it clear that Gwen likes to visit with agencies in her district. James Sensenbrenner’s office also made it clear that they enjoy visiting and touring in the community because it helps them have a better understanding of the issues pertinent to the community.

Please consider setting up an appointment with your representative/senator. I am happy to provide information to you, attend the appointment with you and/or provide any support or assistance you may need.

Much more information to come!

The Advocacy Cabinet

(post author: Dori Ann Bischmann, PhD)

(Psychologists in photo from left to right: John Weaver, PsyD, Greg jurenec, PhD and Dori Bischmann, PhD. Sarah Bowen, WPA executive director took the picture)