Changes Lie Ahead for PQRI and eRx Program

The Centers for Medicare & Medicaid Services (CMS) released June 25 a preliminary version of the 2011 Medicare Physician Fee Schedule (MPFS) proposed rule. The proposed rule contains a number of policy changes that will affect practitioners who are paid under Medicare Part B. Many of the proposed changes are Affordable Care Act (health reform) provisions, which CMS is required to implement. Changes to the Physician Quality Reporting Initiative (PQRI) and the Electronic Prescribing (eRx) Program are among those provisions.

PQRI Changes

Health reform authorizes PQRI incentive payments through 2014, with a penalty thereafter for eligible providers (EPs) who do not satisfactorily report. For 2011, EPs may earn an incentive payment of 1.0 percent of their estimated total allowed charges for covered MPFS services provided during the reporting period.

For the PQRI in 2011, CMS is proposing:

  • Adding 20 individual measures and one new measures group;
  • Making 12 additional individual measures available for reporting through electronic health record (EHR) systems;
  • Reducing the reporting sample requirements for claims-based reporting of individual measures from 80 percent to 50 percent;
  • Creating a new Group Practice Reporting Option (GPRO) that would allow group practices with fewer than 200 EPs to participate;
  • Providing EPs in 2012-2014 with an incentive payment of 0.5 percent their estimated total allowed charges for covered MPFS services provided during the applicable reporting period;
  • Implementing PQRI payment penalties in 2015 for EPs and group practices that do not satisfactorily report data on quality measures by reducing the fee schedule payment by 1.5 percent in 2015 and 2.0 percent in 2016 and thereafter; and
  • Allowing EPs to qualify for an additional 0.5 percent incentive if they satisfactorily report PQRI measures and participate in a Maintenance of Certification program.

E-Prescribing Incentive Program Changes

EPs and group practices who are successful e-prescribers for 2011 may earn an incentive payment of 1.0 percent of their estimated total allowed charges for MPFS services provided during the reporting period. Beginning in 2012, the program will impose penalties on EPs who are not successful e-prescribers. The reporting period for incentive payments under the eRx Incentive Program for 2011 will be the whole calendar year, and incentives will be paid based on the covered professional services furnished by an EP during the reporting year.

The 2011 MPFS proposed rule also clarifies that EPs who participate and qualify for the Medicare EHR Incentive Program (to be established under separate regulations) for 2011 may not receive a separate, additional Medicare eRx Incentive Program payment. However, as the proposed rule further clarifies, EPs who receive incentives under the EHR Incentive Program for 2011 could be subject to a penalty applicable in 2012 for not participating and being a successful electronic prescriber in the eRx Incentive Program in 2011. To that end, the proposed rule establishes criteria for applying the penalty applicable in 2012 or 2013 that EPs (and group practices) may incur if they do not participate successfully in the eRx Incentive Program in 2011 or 2012, including a proposed process for hardship exemptions.

For complete details, read the proposed rule on the Federal Register Public Inspection Desk. CMS is accepting comments on the proposed rule until August 24. The final rule is expected to be published in by Nov. 1. Unless otherwise specified, the new payment rates and policies will apply to services furnished to Medicare beneficiaries on or after Jan. 1, 2011.

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One Response to “Changes Lie Ahead for PQRI and eRx Program”

  1. Liza Enriquez says:

    Q 2 answer C. 1.0% :Correction needed in View Rationales which states “EP’s & gr practices…may earn an incentive payment of 10% of their estimated total allowed charges..” instead of the article “For 2011, EPs may earn an incentive payment of 1.0 percent of their estimated total allowed charges for covered MPFS services provided during the reporting period.” 10% is not =/same as 1.0%

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