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Medicare Primary Care Bonus Payment Program

Bonus Payment Program Overview

Over what period will CMS run the calculation based on the formula above?

The law states that determination as to whether Medicare allowed charges meet or exceed the 60 percent threshold is to be based on a “prior period.” CMS determined that this prior period will be the calendar year two years prior to the incentive payment year for the physicians with such experience. CMS uses data from two years prior to the incentive payment year because it allows it to calculate eligibility using a physician’s complete billing data for that year—the agency has 99 percent of the billing data for a calendar year six months into the subsequent calendar year. This lag time is due to the fact that physicians have up to a year to submit a claim from the date they provided the service as well as that the agency needs to aggregate the data. To illustrate, a primary care physician will receive the bonus payment on top of payment for select primary care services in 2011 if CMS determined that he or she is eligible based on its assessment of billing from 2009.

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