Payment for Reporting

40 – Payment for Reporting (Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12) A participating individual eligible professional or group practice (see §20) who is determined to be a “successful electronic prescriber” (see §60) may earn an incentive payment or receive a payment adjustment with respect to covered professional services furnished by the eligible professional (or group practice) during a specified reporting period (see §30). Section 1848(k)(3)(A) of the Act defines “covered professional services” as services for which payment is made under, or is based on, the Medicare Part B PFS and which are furnished by an eligible professional (or group practice). 9 An eligible professional who is determined to be a successful electronic prescriber may qualify to earn an incentive payment or receive a payment adjustment equal to a percentage of the total estimated Medicare Part B allowed charges for covered professional services furnished by the eligible professional during the respective reporting period. The incentive payments for successful electronic prescribers for each authorized year are as follows: • 2.0 percent for 2009; • 2.0 percent for 2010; • 1.0 percent for 2011; • 1.0 percent for 2012; and • 0.5 percent for 2013. In addition to the eRx incentive payment, under § 1848(a)(5)(A) of the Act, a PFS payment adjustment applies beginning in 2012 to those who are not successful electronic prescribers for 2012. The payment adjustments for eligible professionals who are not successful electronic prescribers for each authorized year are as follows: • 1.0 percent for 2012; • 1.5 percent for 2013; and • 2.0 percent for 2014. The eRx incentive payment amount is calculated based on an eligible professional’s (or group practice’s) total estimated allowed charges for all covered professional services: (1) furnished during the applicable reporting period, (2) received into the National Claims History (NCH) file by no later than 2 months after the end of the reporting period, and (3) paid under or based upon the Medicare PFS. Because claims processing times may vary by time of the year and Medicare Carrier/AB MAC, eligible professionals should submit claims from the end of the reporting period promptly, so that if, for example, the reporting period ends on December 31st of a particular year, claims from the end of the reporting period will reach the NCH file by February 28th of the following year. The eRx incentive payments are paid as a lump sum. Eligible professionals and group practices who receive an eRx incentive will see the following statement on their paper remittance advice: “This is an E-Rx incentive payment.” On electronic remittance statements, the code “LE” and a year indicator (e.g., “RX10 for a 2010 incentive payment) appears on the remittance advice to indicate the amount provided is for an eRx incentive earned. A glossary of these codes is provided for eligible professionals or group practices. The eRx payment adjustment amount is calculated based on the Secretary’s total estimated allowed part B charges for all covered professional services: (1) furnished by the eligible professional (or group practice) during the applicable payment adjustment year and (2) paid under or based upon the Medicare PFS. Eligible professionals and group practices that are subject to a payment adjustment will see the following codes on their remittance advice: CARC #237 (“Legislated/Regulatory Penalty”) and RARC #N545 (“Payment reduced based on status as an unsuccessful eprescriber per the ERx Incentive Program”). If a payment adjustment was applied in error and an eligible 10 professional or group practice is reimbursed due to this error, CARC #237 and RARC #N546 (“Payment represents a previous reduction based on the ERx Incentive Program”) will appear on the remittance advice. A glossary of these codes is provided for the eligible professionals or group practices. Payment for this program is calculated at the individual eligible professional level using individual NPI data and beginning in 2010, for group practices participating in the eRx GPRO, at the group practice level using TIN data. CMS uses the TIN as the billing unit so that any eRx incentive payment earned (regardless of whether the incentive payment was earned by an individual eligible professional or a group practice) is paid to the TIN holder of record. Individual incentive payments for groups that bill under one TIN are aggregated and paid to the holder of the TIN. Some individuals (NPIs) may be associated with more than one practice or TIN, and thus CMS groups claims by TIN for purposes of the incentive. In other words, the incentive payment is made for each unique TIN/NPI combination so that an eligible professional who qualifies for the eRx incentive payment under more than one TIN would receive a separate eRx incentive payment associated with each TIN. Under the statute, however, there is a limitation with regard to the application of the incentive and payment adjustment. The incentive and payment adjustment does not apply to eligible professionals (and group practices participating in the eRx GPRO), for the reporting period, if the Medicare allowed charges for all covered professional services for the codes to which the eRx quality measure applies are less than 10% of the total allowed charges under Medicare Part B for all such covered professional services furnished by the eligible professional (or group practice). The eRx incentive payment and payment adjustment amount is calculated using allowed charges for all covered professional services, not just those charges associated with eRx events. The term “allowed charges” refers to total charges, including the beneficiary deductible and co-payment, not just the 80% paid by Medicare or the portion covered by Medicare where Medicare is a secondary payer. Note that the amounts billed above the Medicare PFS amounts for assigned and non-assigned claims do not apply to the incentive and/or payment adjustment. The statute defines eRx covered professional services as those paid under or based upon the Medicare PFS only, which includes technical components of diagnostic services and anesthesia services, as anesthesia services are considered fee schedule services though based on a unique methodology. Other Part B services and items that may be billed by eligible professionals but are not paid under or based upon the Medicare PFS are not included in the calculation of the eRx incentive and/or payment adjustment amount. Please note that, according to section 1848(m)(2)(D) of the Act, an eligible professional cannot receive an incentive payments under both the Medicare eRx Incentive Program and Medicare EHR Incentive Program. 11 For information on operational payment instructions related to the eRx Incentive Program, please see Chapter 3(§30) of this manual titled “Contractor Incentive Program Payment Operational Instructions.”