The Medicare Improvements for Patients and Providers Act of 2008 provides for e-prescribing financial incentives in 2011 and financial penalties in 2012 and 2013. When you successfully e-prescribe and report on 25 patient encounters, you will be eligible to receive a 1% incentive of the total estimated allowed charges for professional services covered by Medicare Part B rendered in 2011. The big news, however, is the payment reductions for those who do not successfully meet e-prescribing reporting requirements that will be applied–1% in 2012 and 1.5% in 2013.
To be eligible for the e-prescribing program in 2011 you must:
- Have prescribing authority;
- Currently use a qualified e-prescribing system; and
- Have at least 10% of annual Medicare Part B charges come from a list of approved codes,
According to the Centers for Medicare and Medicaid Services (CMS), you should err on the side of e-prescribing if you are unsure whether relevant Part B charges will be at least 10% of total charges.
CMS established the first six months of 2011 as the “2012 e-prescribing payment adjustment reporting period.” This means that if you are eligible for the incentive in 2011 as described above, then you must report the e-prescribing G code—G8553—on at least 10 claims by June 30 in order to avoid the 1% payment reduction in 2012.
Last November, CMS announced the 2012 penalties for providers who are not successful e-prescribers. The penalties are:
- A 1% reduction in Medicare physician fee schedule (PFS) in 2012;
- A 1.5% reduction in Medicare PFS in 2013; and
- A 2% reduction in Medicare PFS in 2014 and beyond.
Three Key Points
- Whether you are a successful e-prescriber or not, and therefore whether a payment reduction will be applied starting 2012, is based at the individual national provider identifier level, not at the practice level.
- By law, you cannot collect incentives from both the e-prescribing and CMS electronic health record (EHR; meaningful use) incentive programs. You should carefully consider which program to focus on for incentive payments. For more information on the CMS EHR incentive program, visit www.rheumatology.org/HIT.
- Even if you are submitting for the EHR incentive program, you must also submit 10 e-prescribing claims by June 30, 2011 to avoid payment penalties in 2012 and 2013.
Will You Get Hit with Penalties in 2012?
If the G code does not appear on at least 10 claims between January 1 and June 30, the 2012 pay reduction will apply unless one of the following conditions is met:
- Your Medicare Part B allowable charges do not clear the 10% hurdle; that is, less than 10% comes from the 56 CPT codes on the eligible e-prescribing encounter list.
- You have fewer than 100 billed encounters with Medicare part B beneficiaries, including the 56 CPT codes during the first six months of 2011.
- A hardship exemption is requested because you practice in a rural area without sufficient high-speed Internet. To qualify for this exception, you must report the code G8642 via claims at least once during the first six months of 2011.
- A hardship exemption is requested because you practice in an area without sufficient available pharmacies for e-prescribing. To qualify for the exception, you must report the code G8643 via claims at least once during the first six months of 2011.
Will You Get Hit with Penalties in 2013?
The answer is yes if you do not successfully report the G code for 25 eligible claims during the 2011 calendar year. You will see your 2013 Medicare PFS reduced by 1.5%. It is possible that the determinants of the 2013 penalties may be changed in the 2012 Medicare PFS; however, if you wait to find out, you may miss the chance to avoid penalty.
If you are eligible for the incentive in 2011, then you must report the e-prescribing G code—G8553—on at least 10 claims by June 30 in order to avoid the 1% payment reduction in 2012.
Remember, the determination of whether you are a successful e-prescriber or not—and therefore whether a payment reduction will be applied—is based at the individual national provider identifier level and is not determined by the participation or success of others in the practice.
Visit www.rheumatology.org/HIT for further instruction on claims reporting and a sample claim.
Next Steps
Participating in the e-prescribing incentive program should be supported with appropriate office procedures. Implementing a system to ensure the e-prescribing G code is successfully reported to CMS for eligible encounters means implementing a process that ensures the G code is applied to the claim being submitted and reviewing explanation of benefits to verify that the G code was received and documented by CMS.
In the case that a patient’s preferred pharmacy cannot receive e-prescriptions, you can still receive credit for generating the e-prescription by listing the G code on the claim. CMS states that using a pharmacy that cannot receive an electronic prescription does not invalidate an e-prescribing event.
If you are not currently e-prescribing, you need to act fast to get a qualified system in place. If you are considering an investment in a full EHR system in the near future or if you would like to take more time to evaluate e-prescribing systems that might be the best long-term fit for your practice, then consider these temporary alternatives to help you gain compliance, qualify for incentives, and avoid penalties:
- Subscribe to an online solution that does not call for a long-term contract; or
- Implement the free National e-Prescribing Patient Safety Initiative system (visit www.nationalerx.com for complete information).
For more information on getting an electronic prescribing system or verifying that your current system is in compliance, visit www.getrxconnected.com. For more information on the CMS e-prescribing program, please visit www.rheumatology.org/HIT or contact Itara Barnes at [email protected].
