Payment in Peril: Why Your Practice Must Act Now to Save Your Financial Bottom Line

• HIPAA 5010
• E-Prescribing
• Physician Quality Reporting System

To avoid severe cash-flow interruption and penalties, your practice must move quickly. Failure to meet various regulatory deadlines and transaction standards could jeopardize almost all of your practice’s third-party payments, and the Centers for Medicare and Medicaid Services (CMS) could assess penalties.

HIPAA 5010: The Race to 2012

What you need to know

• Effective Jan. 1, 2012, will your system be able to transmit this ICD-10 code for diabetes with macular edema: E10.311? If it can't, or if you are not sure, it is time to check in with your system management or support staff to see where things stand with the transition to HIPAA 5010. Ask about their plans for HIPAA 5010 conversion and compliance.
• If systems are not compliant with HIPAA 5010 by Jan. 1, 2012, all claims except Workers Compensation will be rejected and your practice will not get paid. Again: All 4010 transactions will be rejected, beginning Jan. 1.
• Don’t delay! If you have not already started getting your practice ready for HIPAA 5010, you must act immediately. The AMA estimates it could take a medical practice months to become HIPAA 5010 compliant. The time will vary depending on the size of your practice and the resources available to tackle the process.
• HIPAA 5010 is being adopted as part of the process of moving toward ICD-10.
• Do not expect regulatory delays for HIPAA 5010 or ICD-10 implementation, as their deadlines are statutorily mandated and have been delayed once previously. 

More information, plus implementation guidelines: www.aao.org/hipaa5010.

E-Prescribing: Future Penalties Tied to 2011 Non-Participation

What you need to know

• If you e-prescribed a minimum of 10 times before June 30, you need to make sure Medicare Part B receives those claims before July 31 in order to avoid the 1 percent payment adjustment/penalty on 2012 claims.
• The remaining 15 of the 25 e-prescriptions must occur by the end of 2011 in order to not incur the penalty for claims in 2013.
• If you did not e-prescribe 10 times before June 30, there is still time to earn a bonus and avoid the 2013 payment adjustment/penalty, but your practice will need to e-prescribe very regularly.

Are you unable to e-prescribe?

• If your practice has a limited Medicare patient load, it may be exempt from these requirements. Additional exemptions were proposed in a rule CMS released May 26 (open for comment through July 25). Learn more about the proposed additional exemptions.
• There will be a very short window of opportunity to apply for exemptions, so practices should be prepared to quickly document their eligibility to CMS. As soon as CMS announces approval of the exemptions and the appropriate format for submission, the Academy and AAOE will alert members with further information.

More information, plus implementation guidelines: www.aao.org/e-rx.

PQRS (Physician Quality Reporting System)

What you need to know

• It is already too late in the year to qualify for full quality-reporting bonuses via PQRS, if you were going to do it by claims.
• If you are still going the claims route, you can report for the July 1 to Dec. 31 period and get a partial bonus.
• You can still report PQRS for the full 2011 year if you use the alternate registry reporting option.
• Registry reporting includes an additional fee and requires dedicated staff time to enter data.
• Medicare’s Physician Quality Reporting Initiative (PQRI) is now known as the Physician Quality Reporting System (PQRS), and references on CMS have been changed to reflect this change.

What to do

• Check Remittance Advice (RA) notices regularly to ensure receipt of remark code N365 for each PQRS measure submitted.
• More information: www.aao.org/pqri. If you have any further questions, e-mail aaoe@aao.org.