CMS officials disagree, saying in so many words that it's "unfortunate," but these Tennessee doctors skipped over the details on who, and what services, qualified for the additional pay.So for those doubters out there that thought this "physician" Maintenance of Certification (MOC) discussion was a "physician issue" and did not pertain to patient care delivery, think again.
First, CMS rules specified that Medicaid providers had to be board certified in internal medicine, family medicine or pediatrics. These doctors weren't, in part because in rural areas, hospitals often don't require board certification and, for older doctors, it wasn't a mandate after training.
Second, for doctors without board certification, their status as primary care providers could be documented if 60% of the codes they submitted in their claims were for a select set of primary care evaluation and management (E&M) or vaccination services, not specialty services.
MedPageToday: Medicaid Boom Turns to Bust for Tennessee Docs - Lack of certification triggers payback requirement