The In’s and Out’s of Medicare’s E-Prescribing Bonus Program

Published by Steve Hedberg on April 19, 2009 Under Medicare

prescriptionbottleMedicare is a type of health insurance that is funded by the Federal Government and available to seniors over the age of 65 and some others who suffer from specific health conditions, such as kidney failure.

As part of the Medicare Improvements for Patients and Providers Act, some medical professionals may qualify to take part in Medicare’s E-Prescribing Bonus Program.

Below are some frequently asked questions about Medicare’s E-Prescribing Bonus Program.

Who is Eligible for the E-Prescribing Bonus Program?

The E-Prescribing Bonus for Medicare was part of the Medicare Improvements for Patient and Providers Act, which was a piece of legislation approved by congress last year.

Starting in 2009, medical professionals in certain industries who utilize an E-Prescribing System are eligible. Specifically, the program is restricted to doctors and professionals who are authorized to write prescriptions.

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What is E-Prescribing?

E-prescribing is simply when doctors electronically transmit their prescriptions directly to a pharmacy.

Most Electronic Medical Record (EMR) Systems will automatically e-prescribe prescriptions, however an EMR system is not required to E-Prescribe. There may be some systems available for free, but most need to be purchased.

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Do I have to Participate?

No. However, while this is an optional program, starting in 2011 Medicare will begin phasing out the bonus Program and will begin to reduce payments for those who do not use an E-Prescribing System. Penalties for not using an E-Prescribing System are set to start in 2012.

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How do I Enroll?

Enrollment is not required. As soon as an E-Prescribing System is in place, doctors only need to add the appropriate G-Code onto Medicare claims.

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What is a “G” Code?

Each Medicare claim has an associated visit code. In addition to a visit code, claims will now also have a G Code. An appropriate G-Code must be found on at least 50% of all claims to qualify for the bonus.

G-Codes Include:

  • G8443 ā€“ One or More Prescriptions were issued using an E-Prescribing System
  • G8445/ G8446 ā€“ An E-Prescribing System is in place, but no prescription was generated due to patient or system reasons. This can include federal or state law requiring the prescription be phoned in, the pharmacy was not equipped to receive an E-Prescription.

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Are there any Special Requirements or Quotas that must be Met?

In order to qualify the total amount billed for coverage of Part B Benefits, like physical exams, must make up at least 10% of all charges. At least 50 percent of all eligible claims must have an associated ā€œGā€ code.

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What is the Amount of the Bonus?

For 2009 and 2010, doctors who qualify for the Medicare E-Prescribing Bonus will receive a 2% bonus on all Medicare reimbursements. This bonus will drop to 1% for 2011 and 2012, dropping to .5% in 2013.

Starting in 2012, doctors who do not use an E-Prescribing system will be a 1% reduction in total Medicare reimbursements. In 2013 this penalty will increase to 1.5% and 2% in 2014.

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If I am in a group practice, do all Doctors have to Participate?

No, payments are linked to each doctors NPI Number. However, the payments are paid to the owner of the tax ID Number.

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Are there any technical requirements of the E-Prescribing System?

Yes, to qualify the E-Prescribing System Must:

  • Create a complete list of medications
  • Allow the doctor to select a medication and create a prescription that is transmitted electronically to the desired pharmacy.
  • Warn the doctor if an unsafe amount is prescribed or an unsafe situation is presented.
  • Offer low cost relevant alternatives when applicable.
  • Provide information on formulary medications.
  • Provide information about whether the insured is eligible and any authorization requirements.
  • Adhere to Medicare’s Part D Standards whenever possible.

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Do Patients Using Medicare Advantage Plans Qualify?

No. Medicare’s E-Prescribing Bonus is currently only available for patients using conventional Medicare. However, it is possible the MMA company might be offering an incentive program as well.

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