From the House Energy and Commerce Committee:

“Democrats and the Obama administration argue that the $245 billion included for doctors — the approximate 10-year cost of adjusting Medicare reimbursement rates so physicians don't face big annual pay cuts — does not have to be counted in the overall cost of the health care bill. Their only-in-Washington reasoning is that they already decided to exempt it from congressional ‘pay-as-you-go’ rules that require new programs to be paid for. In other words, it doesn’t have to be paid for because they decided it doesn’t have to be paid for.”
 
The Associated Press, July 22, 2009