Billing and Payment in a Health Professional Shortage Area (HPSA)

90.4 - Billing and Payment in a Health Professional Shortage Area (HPSA) (Rev. 1273; Issued: 06-29-07; Effective/Implementation Dates: 10-01-07) In accordance with §1833(m) of the Act, physicians who provide covered professional services in any rural or urban HPSA are entitled to an incentive payment. Beginning January 1, 1989, physicians providing services in certain classes of rural HPSAs were entitled to a 5-percent incentive payment. Effective January 1, 1991, physicians providing services in either rural or urban HPSAs are eligible for a 10-percent incentive payment. Eligibility for receiving the 10 percent bonus payment is based on whether the specific location at which the service is furnished is within an area that is designated (under section 332(a)(1)(A) of the Public Health Services Act) as a HPSA. The Health Resources and Services Administration (HRSA), within the Department of Health & Human Services, is responsible for designating shortage areas. HRSA designates three types of HPSAs: geographic, population, and facility-based. Geographic-based HPSAs are areas with shortages of primary care physicians, dentists or psychiatrists. Population-based HPSAs are designations based on underserved populations within an area. Facility-based HPSAs are designations based on a public or non-profit private facility that is providing services to an underserved area or population and has an insufficient capacity to meet their needs. Section 1833(m) of the Social Security Act (the Act) provides incentive payments for physicians who furnish services in areas designated as HPSAs under section 332 (a)(1)(A) of the Public Health Service (PHS) Act. This section of the PHS Act pertains to geographic- based HPSAs. Consequently, Medicare incentive payments are available only in geographic HPSAs. Although section 1833(m) of the Act provides the authority to recognize the three types of geographic-based HPSAs (primary medical care, dental and mental health), only physicians, including psychiatrists, furnishing services in a primary medical care HPSA are eligible to receive bonus payments. In addition, effective for claims with dates of service on or after July 1, 2004, psychiatrists furnishing services in mental health HPSAs are eligible to receive bonus payments. CMS does not recognize dental HPSAs for the bonus payment program. It is not enough for the physician merely to have his/her office or primary service location in a HPSA, nor must the beneficiary reside in a HPSA, although frequently this will be the case. The key to eligibility is where the service is actually provided (place of service). For example, a physician providing a service in his/her office, the patient’s home, or in a hospital qualifies for the incentive payment as long as the specific location of the service is within an area designated as a HPSA. On the other hand, a physician may have an office in a HPSA but go outside the office (and the designated HPSA area) to provide the service. In this case, the physician would not be eligible for the incentive payment. A/B MAC (B) responsibilities include: Informing the physician community of these provisions; Providing a link to the CMS Web site to access the HPSA automated ZIP code files; Providing a direct link to HRSA’s HPSA database Modifying the claims processing system to recognize and appropriately handle eligible claims; Paying physicians the incentive payments; and Performing post-payment reviews of samples of paid claims submitted using the AQ modifier.