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Update on 2012 Electronic Prescribing (eRx) Payment Adjustment

Statutory Authority/Background

CMS is required to subject eligible professionals who are not successful electronic prescribers to a payment adjustment beginning in 2012. This requirement is outlined in Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (P.L.110-275) (MIPPA).

We listed the requirements for being a successful e-prescriber for purposes of avoiding the 2012 payment adjustment in the 2011 Physician Fee Schedule final rule. In February 2012, all eligible professionals who did not meet these requirements were sent a letter notifying them of this fact.

Significant Hardship Exemption Requests

In response to stakeholder feedback, we also published a standalone eRx rule on September 6, 2011, to provide additional circumstances for eligible professionals to apply for a hardship exemption. Eligible professionals initially had until November 1, 2011, to submit a request for a hardship exemption via the newly-created Quality Reporting Communication Support Page for the 2012 eRx payment adjustment; however this deadline was later extended to November 8, 2011. We finished our review of these requests in February 2012 and are continuing to notify requestors via email whether their request was approved or denied.

Questions and Concerns

Although there is no appeal or review process established for the eRx Incentive Program and payment adjustment, we encourage eligible professionals with questions or concerns about the eRx payment adjustment and hardship exemption requests to contact our QualityNet Help Desk. We encourage you to contact the QualityNet Help Desk as soon as possible to make your concerns around the 2012 eRx payment adjustment known. Through the QualityNet Help Desk, we have been working with eligible professionals and CMS-selected group practices who have questions about eRx payment adjustments and/or hardship exemption decisions. We are handling all hardship exemption requests and any questions or concerns on a case-by-case basis. Eligible professionals should continue to contact the QualityNet Help Desk if they have issues relating to the eRx payment adjustment and/or the rationale for denial of their hardship exemption request.

The QualityNet Help Desk can be reached M-F; 7:00 am - 7:00 pm CMT at 866-288-8912 or via email at qnetsupport@sdps.org.

2013 & 2014 eRx Payment Adjustment

Please note that payment adjustments under the eRx Incentive Program run until 2014. For information on how to avoid the 2013 and 2014 eRx payment adjustments, please visit our Web site at http://www.cms.gov/eRxIncentive. Specifically, eligible professionals should review the MLN Matters Article #SE1206, "2012 eRx Incentive Program: Future Payment Adjustments".

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Electronic Submission of Medical Documentation (esMD) Pilot Project

CMS is working to lessen the burden on physicians by giving them a new way to submit medical documentation- through their Electronic Submission of Medical Documentation (esMD) Pilot Project in response to claims review requests.

CMS employs claim review contractors to find improper payments by selecting a small sample of claims, requesting the necessary medical documentation from the provider, and reviewing claims against the documentation provided to determine if the provider complied with Medicare program rules. This is a time-consuming and cumbersome task for both reviewers and providers. Most medical documentation is currently received by mail or fax.

Under the esMD Pilot Project, physicians that want to electronically submit documentation must either build their own gateway or procure gateway services from a Health Information Handler (HIH). Examples of HIHs include: a health information exchange (HIE), a Regional Health Information Organization (RHIO), an E HR Vendor, a Claim Clearinghouse, or a Health Internet Service Provider (HISP). Health Information Handlers that are participating in this program are required to attend bi-weekly calls with CMS, build a gateway that is compatible with the CONNECT portal, test their system with the CMS gateway contractor, and recruit providers to join this project. CMS anticipates that many providers will obtain services for their own gateway by entering into an agreement with a HIH.

The esMD program is voluntary. For providers that wish to send information electronically, they must access a CONNECT compatible gateway. The esMD project will allow for submission of files in a PDF format. Providers who have paper records and wish to participate in the esMD program may do so as long as there is a way to scan paper records into a PDF file.

Note: The Office of the National Coordinator for HIT (ONC) is working with CMS on this project. The formal launch of the first phase of the project will occur at the Standards and Interoperability Framework Face to Face Meeting on October 18. It is anticipated that Phase 2 of the esMD project will launch in October 2012. During the second phase, CMS claim reviewers will electronically send documentation requests to providers when their claims are selected for review.

Additional information is at www.cms.gov/esMD

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