CMS: Act now to get incentives, avoid payment adjustment

The Centers for Medicare & Medicaid Services (CMS) webinar being offered several times this week had a specific purpose: to explain to providers how their decision to participate in several federal programs or put off participation could affect their incentive payments and payment adjustments in coming years.

“2013 is a critical year for Medicare eligible providers for e-prescribing, the physician quality reporting system (PQRS) and Meaningful Use,” said Patrick Hamilton, a health insurance specialist in the Philadelphia office of CMS. The application of a payment adjustment “will be based on activity you did in a previous time period.”

2015 is the first year that payment adjustments go into effect for PQRS and MU. “For most providers, 2013 is the year we’re going to be looking at your activity to see whether you will be able to avoid those payment adjustments.”

CMS often is asked what universe of claims is used to make determinations about the programs, Hamilton said. It is claims for the fiscal year prior to participation year. So, if a provider is trying to determine whether you are eligible in 2013, you want to determine if you are hospital-based. Hospital-based providers are those that provide 90 percent of their services in either the inpatient or emergency department settings (codes 21 and 23 for place of service).

“Look at your fiscal year 2012 claims. Any claims that start from Oct. 1, 2011, through Sept. 30, 2012. That is the universe of claims we’re looking at. For those practices hiring new physicians, “chances are that the new doc will not be able to participate in Meaningful Use in 2013,” Hamilton said.

For those providers who signed up for the Medicare program and then reached the patient threshold to participate in the Medicaid incentive program, CMS allows for a one-time switch “because you’ve received your first payment and you’re doing so before the end of 2014.” However, by the end of 2014, whatever program you are in is the program you will ride out for MU. Unlike the Medicare incentive program, there are patient volume thresholds that must be met to qualify for the Medicaid program. Generally speaking, you must have a minimum of 30 percent Medicaid patients.

Hamilton went over several milestone dates in 2013 regarding these government programs:

• March 29: 2012 data submission deadline for maintenance of certification vendors for PQRS.
• March 31: If you’re using a registry vendor, this is the deadline for 2012 PQRS data submission. This is the CMS deadline, but vendors may implement an earlier deadline so they can ensure that providers qualify. “Always check with your vendor if their dates don’t coincide with CMS.
• June 30: This is the end of the six-month reporting period that coincides with the 2013 eRx incentive reporting period to avoid the 2013 eRx payment adjustment. It also is the last day to apply for a 2014 eRx hardship exemption.

The main way to avoid being subject to a 2014 payment adjustment is to be a successful e-prescriber in 2012, Hamilton said.

CMS implemented an additional six-month reporting period, Jan. 1-June 30, for the eRx program. By June 30, you must report the eRx measures numerator code at least 75 times between January and June for those with 2-24 eligible providers (EPs). Individual EPs must report 10 times; 25-99 EPs 625 times; and 2,500 times for those with 100 or more EPs. “Do not wait until the last week of June to get the claims in,” said Hamilton. July 26 is the deadline for claims to be counted so you don’t want to risk missing that date to have your claims processed cleanly and entered into the National Claims History.

In the fall, providers will receive feedback reports and will have received incentive payments for last year. If you question the results of your feedback report, you have 90 days from receipt to request an informal review.

Hamilton also discussed several hardship exemptions available for the eRx program. CMS carried over four categories for 2014 payment adjustment. June 30 is the deadline to request an exemption. Again, he said, “Don’t wait until the last minute.” The exemptions are for those in a rural area, those with limited availability of pharmacies with eRx capabilities, those in a practice that prescribes a lot of narcotics that cannot electronically prescribed and those with limited eRx activity. CMS added two new categories specifically for 2014 payment adjustment that tie directly into the MU program. If you quality for either exemption, you do not have to proactively request an exemption. They are:

1. EPs or group practices that participate in MU.  If you achieve MU during the 2014 payment adjustment period, you are exempt. If during that time period you are a successful meaningful user, then you automatically qualify for the exemption. “It’s important to note,” said Hamilton, “that if you started MU in 2011 and you were successful and then you moved into 2012 and you either did not do MU at all or you were not successful, you do not automatically qualify for this hardship exemption. We have to see successful attestation for MU.” If 2012 was your first MU year and you did just 90 days, that counts. However, you are only automatically exempt based on this category if your attestation is received and is clean by June 30, which means April 2 is the last day you can start to get the 90 days in by then.
2. EPs or group practices who demonstrate their intent to participate in the EHR Incentive Program and adoption of certified EHR technology. You must register the certification number of your system between Jan. 1 and June 30.

Some additional, important dates are:

• Oct. 3: This is the last day EPs can begin the 90-day reporting period.
• Oct. 15: For PQRS, this is the last day to elect the administrative claims option to avoid the 2015 payment adjustment.
• Dec. 31: The participation year ends for all programs and is the end of the period to avoid 2014 PQRS payment adjustment.

Regarding the eRx program, if you were a successful e-prescriber in 2012 you will avoid 2014 payment adjustment. If you also attested to MU of certified EHR technology in 2012, you cannot earn an eRx incentive in the same year in which you earn a Medicare MU incentive. If not, you may be eligible to get the 1 percent eRx 2012 incentive payment paid in mid- to late summer of the following year.

If you are not a successful e-prescriber, do you expect to take advantage of the six-month look back period? If yes, you must meet the eRx meausre’s numerator code minimum volume threshold to avoid payment adjustment. If you are new to MU, you cannot earn an eRx incentive in the same year in which you earn a Medicare MU incentive. If you are not a meaningful user but you expect to report the eRx measure’s numerator code at least 25 times by December 31, then you may earn a 0.5 percent incentive payment.

If you didn’t do eRx last year or this year, but you qualify for a hardship exemption, you will avoid 2014 payment adjustment if you apply for an exemption by June 30. If not, you will be subject to 2 percent eRx payment adjustment to Medicare Part B reimbursement in 2014. “This is important because it could affect your MU adjustment. Keep this in mind.”

CMS has made several decision trees available to help providers weed through the various requirements and determine their incentives and payment adjustments. The new CMS eHealth webpage covers these programs as well as several others. And, QualityNet is the first line of information for providers with questions about PQRS and eRx.