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July/August 2010
Clinical Practice Management
Health Reform Law Brings Possible Medicare Payment Changes
Future Payment Cuts Remain a Concern

Congress narrowly avoided a 21.3 percent cut in Medicare payments to physicians earlier this summer, but the temporary fix will end Nov. 30. Unless lawmakers act before then, the cut will return in December 2010 and jump to 30 percent next year, according to the 2011 Medicare Physician Fee Schedule Proposed Rule, released in June. The bad news is one of several items in the proposed rule that could impact ID physicians, their practices, and how they are paid.

Although the proposed rule does not change Medicare’s decision to eliminate payments for consultation codes, it does acknowledge the challenges the decision has caused and asks providers to submit comments about their experience with the new coding policy (see June 2010 IDSA News article). IDSA strongly urges members to submit comments by visiting this website by Aug. 24.

Several changes are slated for the current Physician Quality Reporting Initiative (PQRI), among them the addition of 20 new reporting measures, including those that would allow reporting through claims registries and electronic health record (EHR) systems. Other changes would reduce the claims-based reporting requirement from the current 80 percent of applicable Medicare cases to 50 percent in 2011 and would reduce the minimum practice size eligible to qualify for the group practice reporting option from the current 200 providers to just 2 providers.

As required by the health care reform law, Medicare will also gradually decrease incentive payments for PQRI participation from the current 2 percent level, dropping the figure to 1 percent in 2011 and to 0.5 percent from 2012 to 2014. Starting in 2015, those who do not report through PQRI will see a 1.5 percent penalty.

The health care reform law also requires the Centers for Medicare and Medicaid Services (CMS) to establish a separate PQRI reporting option allowing  physicians to submit quality measures data to a Maintenance of Certification Program operated by a specialty body of the American Board of Medical Specialties. Physicians would still need to submit quality data through Medicare claims or qualified-registries. But this new option offers the potential to earn 0.5 percent in extra PQRI incentive payments.

Separately, physicians can still earn additional incentive payments for e-prescribing. The requirements to earn these payments will not change significantly for 2011: Physicians must generate at least 10 percent of their total Medicare charges from outpatient evaluation and management (E&M) service codes, and they must successfully e-prescribe at least 25 times during these situations. Similar to the PQRI option described above, the group practice reporting option for e-prescribing is being modified to account for smaller practices. Incentive payments would drop to 1 percent in 2011-2012, and starting in 2012, those who don’t e-prescribe will face payment penalties. Physicians who earn an incentive under the Medicare EHR Incentive Program for use of technology with these capabilities will not be eligible to earn a separate e-prescribing incentive payment.

For more information about Medicare’s incentive payment programs, see this CMS tipsheet. A tipsheet focused on incentives for EHR use is available here. In another step mandated by health reform, the rule will establish a new “Physician Compare” website by Jan. 1, 2011. Initially, the publicly available website will only report the names of physicians and group practices that successfully earn PQRI and e-prescribing incentive payments.  In future years, the website will combine data about individual physicians’ or groups’ quality and cost of care into a composite score benchmarked against their peers.

Finally, the maximum period for submitting claims to Medicare has been reduced to 12 months from the date of services.  Previously, providers could wait up to three years to submit Medicare claims. IDSA continues to analyze the proposed changes and will be submitting comments to the Centers for Medicare and Medicaid Services (CMS). A final rule is expected Nov. 1. See IDSA’s website for more information about quality improvement resources and tools, including more details about the PQRI and e-prescribing incentive payment programs.
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