Medicare Compliance & Reimbursement

If you're looking for PQRI payments from your Medicare Advantage payers, you may not be out of luck. That's the word from CMS staffers, who clarified the issue during a May 12 CMS-sponsored Physician Quality Reporting Initiative (PQRI) national provider call.

To eliminate confusion that has abounded throughout the medical community, CMS wanted to confirm that eligible professionals can, in some cases, collect PQRI bonuses for providing care to Medicare Advantage patients, said CMS's Francis Szeflinski during the call. "It's very limited," he said, because you must consider first whether your contract with your Medicare Advantage (MA) organization indicates that it will pay the additional PQRI money to you. If it isn't in your contract, the MA organization is not required to pay you the PQRI bonus.

Caveat: If you don't have a written contract with an MA organization, "the general rule is that as a physician or other provider type, an MA organization, when they pay for services that you render to the Medicare Advantage patients, has to pay the same as Medicare. We consider that to mean that if you earn a PQRI bonus under fee-forservice, then that means that the MA organization for those non-contracting members that you've treated for them, also owes you a bonus," Szeflinski said.

You don't need to submit PQRI information directly to the MA contractors, Szeflinski said. If you are entitled to a PQRI bonus from an MA plan, the MA contracting organization will get the bonus amounts directly from the fee-forservice contractors, Szeflinski said.

Practices that received 2008 PQRI bonuses which didn't appear to be up to par may soon get a check that makes up the difference. Some technical issues were discovered regarding 2008 PQRI payments that were issued previously, and although the magnitude of the errors was not particularly wide, "CMS did initiate making payment adjustments that many of you may have noticed already," said Michael Rapp, MD, director of CMS's quality measurement and health assessment group. "We would expect that they would be finished with this no later than May 21," he said. "In a lot of instances, the amount of the additional incentive payment that the eligible professionals will get will be quite small ... but nevertheless, they're being made." If you receive paper checks, you'll get a check for the adjustment amount with a message noting, "this is a PQRI incentive payment," and if you receive electronic remittances, look for provider adjustment reason code "LE," followed by "PQ08," indicating that the payment refers to an incentive payment adjustment for the 2008 PQRI, Rapp said.

PQRI payments for 2009 will begin in "late summer, early fall," Rapp said, but have not been issued yet.

New cycle starts soon: If you have yet to dive into the PQRI program, you still have time to get in on this year's offering, CMS staffers noted.

"It's not too late to join the growing number of eligible professionals who are participating and receive the 2010 PQRI bonus of up to two percent of the total Medicare Part B allowed charges for the 2010 reporting period," said CMS's Jacquelyn Kosh-Suber during the call. "We'd like all who are interested to participate using the six-month claim or registry reporting option starting July 1, 2010," she indicated.