10% Raise for Primary Care

Physicians who continue providing primary care services to Medicare patients stand to get a 10 percent pay raise under the health reform act.

Increasing medical costs and decreasing Medicare reimbursement rates have put a lot of physician practices in a financial bind. To stay afloat, many physicians have made the difficult decision to stop accepting Medicare patients. The Patient Protection and Affordable Care Act of 2010 (commonly referred to as the Affordable Care Act) includes a provision to turn this trend around by offering incentive payments to physicians and non-physician practitioners (NPPs) who continue to provide primary care services to Medicare patients.

Evaluation and Management – CEMC

Under the Primary Care Incentive Payment Program (PCIP), eligible primary care practitioners (PCPs) stand to earn incentive payments for primary care services furnished to Medicare patients on or after Jan. 1, 2011 through Dec. 31, 2015.

Quarterly incentive payments to participating PCPs are equal to 10 percent of the amount paid under Medicare Part B for primary care services furnished to Medicare patients.

Defining Primary Care Practioners

The Affordable Care Act defines a PCP as:

  • A physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or
  • A nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA) for whom primary care services accounted for at least 60 percent of the allowed charges under the Medicare Physician Fee Schedule (MPFS) for the practitioner in a prior period as determined appropriate by Health and Human Services (HHS)—the federal agency that governs Medicare.

The PCIP is open to all PCPs who submit claims under their own National Provider Identifier (NPI), which is how they will be identified for incentive payments, and who meet or exceed the required 60 percent threshold of allowed charges for primary care services to Medicare patients. For 2011 payments, Medicare claims data from two years prior will be considered to establish the required threshold. A provision to accommodate newly enrolled Medicare providers will be released in 2011.

Services furnished incident-to physicians’ services do not qualify for incentive payments.

Defining Primary Care Services

The Affordable Care Act defines primary care services as those services identified by the following CPT® codes:

  • 99201 – 99215 for new and established patient office or other outpatient evaluation and management (E/M) visits;
  • 99304 – 99340 for initial, subsequent, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home (e.g., boarding home), or custodial care E/M services; and domiciliary, rest home (e.g., assisted living facility), or home care plan oversight services; and
  • 99341 – 99350 for new and established patient home E/M visits.

Source: MLN Matters article MM7060


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3 Responses to “10% Raise for Primary Care”

  1. Mary Emerson says:

    I think this is an issue that desperately needed to be addressed. There are Medicare beneficiaries who moved to a new town or state and have a hard time finding a new
    physician to assume care. This happened to my own parents after they moved to be
    closer to family members when they began to need help living independently, and it
    was very difficult finding a PCP for them.

  2. Ravinder says:

    Excellent decision for both Beneficiaries and Providers to keep things moving as decreasing Medicare reimbursement is a real cause of concern for providers. Hope this will be a great relief.

  3. Karen Slade says:

    My provider is a PA however she bills under a group NPI as she is the owner of her clinic. She has been credentialed as a group just in case she adds providersdown the road. She has been opened for two weeks and already has three Medicare patients who have had their initial visits. Will she be included in the incentive payments?

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