By Roger Jordan, O.D., FAAO, chair of the AOA Federal Relations Committee, and Gary Robbins, executive director of the Kansas Optometric Association and member of AOA Health Information Technology Subcommittee
Medicare has had an electronic-prescribing (e-Rx) incentive program for the last four years. During this period, the program has never required an optometrist to use electronic medical records.
Stand-alone vendors, such as Allscripts, can be used and successfully fulfill the incentive. The incentive has been 2 percent in previous years and is 1 percent in 2011. Overall, the payment is based on the total Medicare-allowed charges for professional services.
Using the most recent results from 2009, overall 1,559 optometrists earned a bonus for that year. This was the sixth highest among physician specialties. The Centers for Medicare & Medicaid Services (CMS) paid optometrists $1,973,493.78 for 2009. Ophthalmology had the third highest participation rate.
In 2010, a subsection in the proposed 2011 fee schedule dealt with e-prescribing. As we all know, optometrists are recognized as physicians in the Medicare program, but the CMS proposed only to penalize some physicians (MD/DO, podiatrists) for not participating in the program.
The AOA argued in its response that optometrists have prescribing privileges and should be held to comparable standards as other physicians under Medicare. Optometry already participates and gets payment for qualifying under the e-Rx incentive program.
The CMS limited the penalties to just MD/DO/ DPM physicians because officials felt that other physicians (including optometrists) do not prescribe.
Congress authorized the e-Rx penalty beginning in 2012. Instead of recouping a penalty from physicians retroactively, the CMS looks at the first six months of the previous year to penalize the current year.
So the 2012 penalty is based on the time period of January through June 2011. The AOA argued against this in rulemaking, but the CMS did not listen.
The AOA did support the modification to the 2012 and 2013 e-Rx incentive program that would allow physicians to report G8853 (prescribing using e-prescribing) on any claim in connection with a service.
This provides more flexibility to various practice modalities in which physicians provide evaluation and management (E&M) services and other primary care services, but happen to write prescriptions only related to more procedure-focused encounters with patients.
Also at the request of the AOA, the CMS added an exception from the penalties for doctors who have the legal right to prescribe, but don’t happen to write prescriptions as part of their patient care.
The CMS has proposed additional policies for the 2013 penalty, but those are not expected in final rule announcement until November 2011.
To further explain the program and penalties: Optometrists can and should participate in e-Rx, but are initially exempt from penalty.
The CMS stated that physician specialties other than MD/DO/DPM generally do not prescribe, yet optometry has prescriptive authority nationally to do topical and oral agents.
Below are the important changes coming:
- Optometrists are eligible for bonus payments. The remaining bonuses are:
- 2011 (paid in 2012 based on 2011 charges): report 25 eRX (G8553) to earn a 1 percent bonus payment.
- 2012 (paid in 2013 based on 2012 charges): proposed to report 25 e-Rx’s (G8553) to earn 1 percent bonus payment.
- 2013 (paid 2014): 0.5 percent bonus payment available
- Optometrists are not yet subject to penalty adjustments, but that could change for 2013 and 2014.
- 2012 (affecting 2012 charges): 1 percent penalty not applicable to optometrists
- 2013 (affecting 2013 charges): 1.5 percent penalty might be applicable to optometrists who do not report 25 e-Rx’s (G8553) during calendar year 2011 or do not report 10 eRX (G8553) in first six months of 2012 or do not meet one of the other exemptions from the e-Rx penalty.
- 2014 (affecting 2014 charges): 2 percent penalty that might be applicable to optometrists.
There is a process for physicians to opt-out under certain hardship situations. The new hardship rules will take effect Jan. 1, 2012. The deadline to apply for the hardship has been pushed back from Oct. 1 to Nov. 1, 2011.
Practitioners will be exempt if already participating in the electronic medical record incentive program, cannot e-prescribe due to state or local rules, prescribe very infrequently, provider services are not included in the program, practice in a rural area without access to high-speed Internet or in an area without sufficient pharmacies available to e-prescribe.
Remember optometry is not affected or required to do anything regarding this ruling yet.
When optometrists register and attest to meaningful use with their certified electronic records, they are unable to accept incentive payments from both the e-Rx and meaningful use incentive programs.
Because e-prescribing is one of the core requirements in meaningful use, the CMS will not make payments for both, just meaningful use, unless the e-Rx payment would be higher (in 2011, this could happen for doctors who are paid more than $2 million by Medicare alone).
Regarding meaningful use, optometrists must demonstrate “meaningful use” to earn the bonus in any given year.
Stage 1 meaningful use applies to 2011 and 2012. One may demonstrate meaningful use over the course of 90 days in the first year, but must show meaningful use for the entire year for bonuses in subsequent years. One may not overlap 2011 and 2012.
The Stage 2 has not been proposed by the CMS. We believe the proposal for 2013 and beyond will come out in January 2013.
The 2006 Tax Relief and Health Care Act required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered professional services to Medicare beneficiaries.
The program initially called the Physician Quality Reporting Initiative (PQRI) started in 2007, but was renamed in 2011 to the Physician Quality Reporting System (PQRS).
The Secretary for the U.S. Department of Health & Human Services is required to post on the CMS Web site, in easily understandable format, a list of names of eligible professionals (or group practices) who satisfactorily submitted data on quality measures for the PQRS.
The evidence-based measures are developed by clinicians and must be endorsed by the national consensus group known as the National Quality Forum (NQF), which includes the AOA.
The measures specifications may be different from prior years so professionals need to ensure that they are using the Physician Quality Reporting documents for the correct program year.
Visiting the CMS Web site can ensure that an optometrist is using the correct measures for the year. The measures are updated at the beginning of each program year.
Individual eligible professionals do not need to sign up or pre-register in order to participate in the PQRS.
In order to qualify for the incentive payment, an eligible professional must meet the criteria for satisfactory reporting specified by the CMS for a particular reporting period.
Professionals should select at least three applicable measures to submit to attempt to qualify for the incentive payment.
If fewer than three measures are reported, the CMS will apply a measure-applicability validation (MAV) process when determining incentive eligibility.
Each measure has a QDC (a CPT II code or G-code) associated with it.
Also, there is a reporting frequency or timeframe requirement (called a measure tag) for each eligible patient seen during the reporting period.
The individual eligible professional who meets the criteria for satisfactory submission of PQRS quality measures data for services furnished during a reporting period will qualify for an incentive payment equal to 1 percent in 2011 of their total estimated Medicare Part B allowed charges for covered professional services (including deductible and coinsurance) furnished during the same reporting period.
The PQRS incentive payment program will become a penalty program in 2015, and penalties may apply to physicians who are not successfully participating in PQRS as soon as 2013.
The hope is that PQRS will result in improved patient care. We anticipate that the CMS will move to a true “pay for performance” system in the future.
As with eRx, about 2,000 optometrists earned approximately $2 million from PQRS in 2009.
The deadline to apply for an EHR hardship exemption is now Nov. 1, 2011.
AOA members with questions should contact the AOA Washington office at 800-365-2219 or at ImpactWashingtonDC@aoa.org.