The e-Prescribing Penalty: A Snake in the Grass?

At the annual RPA meeting last week in Washington, D.C., I entertained several questions related to the CMS e-prescribing penalty. I have described this penalty in other venues and in this blog. Organized medicine is also working diligently to get the word out. In an effort to widely disseminate this information, let’s review what we know about this CMS pay-for-reporting program.

 

The CMS e-prescribing program has been around for a few years. It began as an individual PQRI measure in 2008. The following year, CMS initiated the stand alone eRx incentive program. Participation was challenging in 2009 as the rules of engagement were onerous. That changed last year when the programs requirements became substantially easier. All providers successfully participating last year can expect to receive 2% of their entire Medicare part B allowable charges for 2010 later this fall as a well-deserved bonus for participation. For many nephrologists this incentive will be substantial and in some cases it may reach five figures. The incentive for 2011 is not as rich (it declines to 1% of allowable charges for the year).

 

Of course today’s post is not about the financial windfall of past participation, but instead is a warning about the impending penalty. The challenge facing nephrologists and all other Medicare providers today is the penalty for not e-prescribing in 2012. As a provider, if I am deemed a non-prescriber for 2012, my Medicare Physician Fee Schedule (PFS) will be “adjusted” by 1%. In the parlance of CMS we all must recognize the combination of the word “adjustment” and our PFS is never a good thing. Non-e-prescribers in 2012 face a 1% haircut for all services rendered related to Medicare part B.

 

The snake in the grass?
From my perch it is the mechanism by which CMS will identify those to penalize in 2012. Effectively CMS is observing your behavior in during the first 6 months of this year. In order to avoid the penalty in 2012 one of the following must happen during the first 6 months of 2011 (the so called 2012 e-prescribing adjustment reporting period):

 

1. The provider generates and transmits at least one prescription electronically for a Medicare part B beneficiary during 10 eligible encounters (essentially office encounters for the nephrologist) and conveys this to CMS by placing the e-Rx G-code (G8553) on the claim.
2. The provider has less than 100 eligible encounters with Medicare part B beneficiaries.
3. Less than 10% of the provider’s Medicare part B allowable charges originate from the CPT codes in the eRx denominator (again these are office based encounters for the typical nephrologist).
4. The provider practices in a setting without access to broadband Internet.
5. The provider practices in a setting without access to pharmacies capable of receiving electronic prescriptions.

 

What does this mean for you?
Unless you practice in a remarkably rural part of this country, you must send a script electronically for 10 part B patients you see in the office during the first 6 months of this year and convey this to CMS by placing the G-code on the claim. You are exempt from the penalty if more than 90% of your allowable charges occur outside of the office (interventional nephrologists will likely fall into this bucket). You are also exempt if you are rarely in the office (less than 100 encounters with part B patients in six months which is about four per week).

 

Is this really a snake in the grass?
I’ll let you judge for yourself, but first let me mention two other points of concern. Suppose you elect to participate in the 2011 e-prescribing program to capture your 1% bonus. You can do so by submitting the eRx G-code on 25 eligible part B patients during 2011 as well as by submitting that information through a qualified PQRS registry. However, even if you are successful and are due the financial incentive for your success in 2011, if you do not put the eRx G-code on 10 claims during the first 6 months of this year you will be subject to the penalty in 2012.

 

What about meaningful use?
As you may recall eRx is one of the core measures for meaningful use. One might imagine that if you successfully demonstrate meaningful use in 2011 you would not be hit by the 2012 eRx penalty. Not so fast, the snake will still bite you unless you submit the eRx G-code on 10 part B claims during the first 6 months of 2011.

 

What can you do if you find yourself without the ability to e-prescribe today?
Unless you are in the middle of an EHR implementation, I would strongly urge you to visit the Surescripts website and identify an inexpensive eRx tool. Some of these are free (of course you should remember there is no such thing as a free lunch). Purchase and install the software quickly and knock out your 10 prescriptions before June 30, 2011. While you are at it, send 15 more before the end of 2011. If you send at least one script electronically during an encounter with 25 eligible part B beneficiaries during the course of the year you will receive the 1% bonus for the work you have done, which will more than pay for your eRx software and avoid the snake in the grass.