As 2011 gets under way, many family physicians have questions about how they can receive the Medicare primary care incentive program bonus outlined in the Patient Protection and Affordable Care Act, and the AAFP is providing guidance for them.
According to Cynthia Hughes, C.P.C., an AAFP coding specialist and co-author of Family Practice Management's Getting Paid blog, the incentive program calls for bonus payments equal to 10 percent of the Medicare-paid portion (i.e., 80 percent) of a primary care health professional's allowed charges under Medicare Part B for primary care services provided on or after Jan. 1, 2011, and before Jan. 1, 2016.
Family physicians must meet a minimum requirement of 60 percent of their allowed charges under the Medicare physician fee schedule to receive the bonus, and the AAFP recently worked with CMS to change its implementation rules for the incentive program to allow approximately 20 percent more family physicians to qualify for the program than previously anticipated.
According to Hughes, family physicians do not need to take any action regarding the quarterly bonus payments forthcoming in 2011 because CMS has already identified the names and national provider identifier numbers, or NPIs, of physicians and other eligible professionals who qualified. CMS will pass that information along to Medicare administrative contractors before Jan. 31 of each incentive year.
For 2011, CMS based physician eligibility on 2009 claims data, and the first bonus checks should arrive in physician practices sometime after March 31.
In an interview with AAFP News Now, Hughes highlighted some specifics of the program that family physicians should keep in mind for 2012 and beyond.
- FPs who work in a group practice should make sure they are listed as such on their Medicare enrollment form.
- Payment will be assigned to the practice unless a physician is listed in CMS enrollment data as the operator of a solo practice.
- Physicians who employ a mid-level provider, such as a nurse practitioner or physician assistant, should use the physician's NPI number for the billing of applicable primary care services provided by any nonphysician health care professional to ensure the services are credited to the physician for purposes of the incentive qualifiers.
Hughes advised physicians to ask their Medicare contractors for a list of primary care physicians eligible for a bonus in 2011. "Presumably, if a physician's name is not there, the physician has not performed the 60 percent of primary care services required," said Hughes. However, if a physician doesn't see his or her name on that list and thinks he or she is qualified, then a phone call to the Medicare contract administrator is in order, she said.
"The problem could involve a minor glitch with the physician's Medicare enrollment form," said Hughes, adding that the first item to check is the taxonomy code showing the physician's specialty.
Only physicians with a primary specialty designation of family medicine (code 08), internal medicine (code 11), geriatric medicine (code 38) or pediatric medicine (code 37) qualify for the incentive program.
One unanswered question is how medical group practices will disperse primary care incentive payments.
Bruce Bagley, M.D., the AAFP's medical director of quality improvement, formerly practiced in a large medical group practice in Albany, N.Y. His background led him to speculate that, in most situations, the bonus checks would go directly into the general revenue for the practice rather than be distributed to individual physicians in the practice.
"Practices will decide what to do with the money, but in many cases, practice managers will put that extra money on the revenue side and just keep on going," Bagley told AAFP News Now. In some cases, he added, "physicians won't even know they earned the bonus."
Hughes noted that some practice managers with whom she has communicated indicated that they would use the incentive payments to help fund purchase of electronic health records for their practices.
Bagley suggested that practice managers should alert office personnel that a "different kind of check" would be coming in from Medicare contractors.
"These checks will not be attached to a single billing and should be recognizable to the front office staff members as something different," said Bagley. However, some billing personnel may be unaware of the incentive program.
Although the bonus is helpful, the AAFP notes that it isn't a solution to the inequality in physician pay.
"I think my family physicians colleagues can expect to get a little more money, and they'll be happy when it comes across, but they shouldn't expect to see huge checks that they'll personally pocket from this program," said Bagley.
A white paper issued by the Robert Graham Center in May 2009 and titled "Effects of Proposed Primary Care Incentive Payments on Average Physician Medicare Revenue and Total Medicare Allowed Charges(www.graham-center.org)" estimated that the average family physician's annual Medicare revenue would increase by $1,977 with a projected 5 percent incentive payment; a 25 percent incentive payment would yield $9,884.
The amount of incentive money earned by FPs who qualify for the 10 percent primary care bonus stipulated in the health care reform law would fall somewhere in between.