Participation by Group Practices Using the eRx Group Practice

20.2 – Participation by Group Practices Using the eRx Group Practice Reporting Option (GPRO) (Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12) Prior to 2010, the eRx Incentive Program was limited to participating as an individual eligible professional and the determination of whether an eligible professional is a successful electronic prescriber was made at the individual professional level, based on the National Provider Identifier (NPI). No incentive payments were available to a group practice based on a determination that the group practice, as a whole, was a successful electronic prescriber. To the extent that individual eligible professionals (based on individuals’ NPIs) are associated with more than one practice, or Taxpayer Identification Number (TIN), the determination of whether an eligible professional is a successful electronic prescriber was made for each unique TIN/NPI combination. Therefore, the incentive payment amount was calculated for each unique TIN/NPI combination and payment was made to the holder of the applicable TIN (see §40 below). As required by the MIPPA, beginning in 2010, group practices, by participating in the eRx group practice reporting option (GPRO), are eligible to qualify for an eRx incentive payment based on the determination that the group practice, as a whole, is a successful electronic prescriber. The criteria for determining whether a group practice is a successful electronic prescriber and the process for reporting by group practices under the eRx GPRO are discussed in §60.2 below. In 2010, for purposes of being able to participate in the eRx Incentive Program under the eRx GPRO, a “group practice” was defined as a TIN with at least 200 or more individual eligible professionals (as identified by NPIs) who have reassigned their billing rights to the TIN. However, in 2011, with the addition of “GPRO II” described in Chapter 1, § 20.3, the definition of group practice was expanded to include a TIN with at least 2 or more individual eligible professionals (as identified by NPIs) who have reassigned their billing rights to the TIN. In 2012, the definition of group practice for the eRx Incentive Program was further modified to mirror the 2012 definition of group practice for the 2012 Physician Quality Reporting System as described in Chapter 1, § 20.3 of this manual. Therefore, a group practice was defined as a TIN with at least 25 or more individual eligible professionals (as identified by NPIs) who have reassigned their billing rights to the TIN. In 2012, the definition of group practice also includes those groups participating in certain Medicare- approved demonstrations projects or various other CMS programs, under which Physician Quality Reporting System requirements and incentives have been incorporated, such as groups participating in the Medicare Shared Savings Program. 7 In order to participate in the eRx Incentive Program through the GPRO, including those groups that are deemed participating in the Physician Quality Reporting System, group practices must have self-nominated and been selected to participate in the Physician Quality Reporting System GPRO (see Chapter 1, §20 for information on the requirements for participation in the Physician Quality Reporting System GPRO). CMS assesses whether the participation requirements are met by each self-nominated group practice and notifies group practices of a decision. As required by section 1848(m)(3)(C)(iii) of the Social Security Act (the Act), an individual eligible professional who is a member of a group practice selected to participate in the eRx GPRO for a particular program year is not eligible to separately earn an eRx incentive payment as an individual eligible professional under that same TIN (that is, for the same TIN/NPI combination) for that year. Once a group practice (TIN) is selected to participate in the GPRO for a particular program year, this is the only method of eRx Incentive Program participation available to the group and all individual NPIs who bill Medicare under the group’s TIN for that program year. In addition, the group practice will be assessed for applicability of the payment adjustment, beginning in 2012, discussed in § 60.2.2 below under the GPRO criteria as well. Although the determination of whether a GPRO is a successful electronic prescriber will be analyzed at the TIN level, if group practices elect to participate in the eRx GPRO for a particular program year and the group practice fails to meeting the reporting thresholds for reporting its eRx activities (i.e., fails to become a successful electronic prescriber), each eligible professional who belongs to the group practice will be subject to the payment adjustment, regardless of whether or not the eligible professional, as an individual, successfully reports . For example, for purposes of the 2012 payment adjustment, if a group practice consisting of 2 individual eligible professionals elects to participate in the eRx GPRO under the 2011 eRx GPRO II option, based on the size of this group practice (which is 2), this group practice must report the eRx measure via claims on 75 unique events for patients in the denominator of the measure for services occurring between January 1, 2011 and June 30, 2011. If an eligible professional within the group practice reports the eRx measure on 25 unique events during the January 1, 2011 and June 30, 2011 reporting period and the other eligible professional does so for only 5 unique events , provided a limitation or significant hardship exemption does not apply to the group practice, the group practice as a whole (i.e., both individual eligible’s) will be subject to a 1.0% payment adjustment on all their Medicare Part B PFS allowed charges for covered professional services furnished in 2012. Although the first eligible professional would have successfully reported as an individual, the entire group practice (i.e., both eligible professionals) will be subject to the 2012 payment adjustment for failing to reach the reporting threshold of 75 unique events that was required for groups with 2 eligible professionals.