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Medicare Primary Care Bonus Payment Program

Bonus Payment Program Overview

As a result of ACP advocacy, many general internists will receive a boost in payments from Medicare beginning in 2011. The College was a driving force behind Congress’ creation of a program that makes bonus payments to primary care physicians for primary care services, and most recently, ACP persuaded the Centers for Medicare and Medicaid Services (CMS) to greatly expand the number of internists who will qualify for the bonus. ACP estimates that a typical office-based, general internist who qualifies for the bonus would get approximately $5,000 in Medicare revenue each year for the next five years, although the exact benefit for any individual internist will depend on their mix of services.

Congress established this bonus program, the Primary Care Incentive Payment program, through the March 2010 federal health care reform law, the Patient Protection and Affordable Care Act (ACA). The College has also played a major role in shaping the rules established by CMS to implement the program. The CMS rules, which the agency announced in early November 2010, ensure that the bonus payments will be made to most general internists and other primary care physicians.

Medicare uses a fee schedule to pay physicians for the services they furnish to beneficiaries. The ACA provides a 10 percent bonus payment on top of the fee schedule payment for select primary care services furnished by primary care physicians in calendar year 2011-2015. To qualify for the bonus, a physician must be self-designated in a primary care specialty (general internal medicine, family practice, pediatrics, and geriatrics) and a substantial portion (60 percent) of their Medicare billings (allowable charges) must be for the designated primary care services (mainly, office-and other outpatient visits) on which a bonus payment is made. CMS will assess eligibility for the bonus by (1) checking a physician’s specialty self-designation to ensure that they are in general internal medicine or in another primary care specialty and (2) looking back on the percentage of designated primary care services furnished by the physician during an earlier time period.

Primary care physicians who qualify will receive a bonus payment at the end of each quarter of the each payment year (2011-2015) in which they qualify. CMS will determine which physicians qualify on an annual basis. The 10 percent bonus payment will be made in addition to the Medicare payment for each select primary care service, e.g. office visit, furnished and billed during each quarter, with the total bonus payment amount for the quarter dependent on the number of primary care services provided during that quarter.

CMS estimates that approximately 60 percent of general internists will qualify and receive a quarterly bonus payment in 2011. As the 60 percent figure is based on the total number of physicians with a general internist Medicare specialty designation, which includes many hospitalists and some other general internists who do not provide office-based primary care, the percentage of office-based general internists who qualify will be substantially higher than 60 percent. Hospitalists do not qualify because Congress wanted to create incentives for physicians who enter and remain in office-based primary care specialties. Hospitalists, because they generally do not bill for the office-based primary care visits, would, therefore, not meet the requirement that 60 percent of their Medicare allowable charges be for such office-based visits. Subspecialists not designated as general internists also cannot qualify, because Congress specifically wanted to target the bonus to create incentives for physicians to enter and remain in the primary care fields of general internal medicine, family practice, pediatrics, and geriatrics.

Check your Medicare contractor’s website for a listing of the physicians in your area who qualify for the 2011 bonus payments. Each Medicare contractor should have its qualifying physician list posted prior to the beginning of 2011. If you do not know it, CMS provides contractor-specific contact information at: http://www.cms.gov/MLNProducts/Downloads/CallCenterTollNumDirectory.zip.

If you qualify, you do not have to take any action. You will receive your first bonus payment installment shortly after the first calendar year quarter concludes on March 31.

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