The Pulse

Knowledge is power. "The Pulse" is our way of keeping you informed of industry news, market trends and what's happening at IPMS. Stay informed so you can stay ahead. Check back often for updates!



HHS Proposes Stark Law and Anti-Kickback Statute Reforms to Support Value-Based and Coordinated Care

Today, the Department of Health and Human Services (HHS) announced proposed changes to modernize and clarify the regulations that interpret the Physician Self-Referral Law (the “Stark Law”) and the Federal Anti-Kickback Statute.

The proposed rules provide greater certainty for healthcare providers participating in value-based arrangements and providing coordinated care for patients. The proposals would ease the compliance burden for healthcare providers across the industry, while maintaining strong safeguards to protect patients and programs from fraud and abuse.

The proposed rules are part of HHS’s Regulatory Sprint to Coordinated Care, which seeks to promote value-based care by examining federal regulations that impede efforts among providers to better coordinate care for patients.

“President Trump has promised American patients a healthcare system with affordable, personalized care, a system that puts you in control, provides peace of mind, and treats you like a human being, not a number. But too often, government regulations have stood in the way of delivering that kind of care,” said HHS Secretary Alex Azar. “Regulatory reform has been a key piece of President Trump’s agenda not just for faster innovation and economic growth, but also better, higher-value healthcare. Our proposed rules would be an unprecedented opportunity for providers to work together to deliver the kind of high-value, coordinated care that patients deserve.”

“These proposed rules would be a historic reform of how healthcare is regulated in America,” said HHS Deputy Secretary Eric Hargan. “They are part of a much broader effort to update, reform, and cut back our regulations to allow innovation toward a more affordable, higher quality, value-based healthcare system, while maintaining the important protections patients need. Here at HHS, CMS and the Office of Inspector General recognized the need for reform and have acted to produce serious and thoughtful sets of proposals.”

The Stark Law’s new value-based exceptions, under the proposed rule issued by the Centers for Medicare & Medicaid Services (CMS), acknowledge that incentives are different in a healthcare system that pays for value, rather than the volume, of services provided. They include proper safeguards that ensure the Stark Law will continue to provide meaningful protection against overutilization and other harms, while giving physicians and other healthcare providers added flexibility to improve the quality of care for their patients.

“We serve patients poorly when government regulations gather dust in the attic: they become ever more stale and liable to wreak havoc throughout the healthcare system,” said CMS Administrator Seema Verma. “Administrative costs are driving up the cost of healthcare in America – to the tune of hundreds of billions of dollars. The Stark proposed rule is an important next step in President Trump’s healthcare agenda for Americans. We are updating our antiquated regulations to decrease burden for providers and helping bring down these increasingly escalating costs.”

The proposed changes to the regulations related to the Federal Anti-Kickback Statute and the Civil Monetary Penalties Law issued by the Office of Inspector General (OIG) would, if finalized, address the longstanding concern these laws unnecessarily limit the ways in which healthcare providers can coordinate care for patients. The changes would offer flexibility for beneficial innovation and improved coordinated care through, for example, outcome-based payment arrangements that reward improvements in patient health. The changes would also make it easier for physicians and other healthcare providers to ensure they are complying with the law by offering specific safe harbors for these arrangements.

“Any patient can tell you how difficult it is to coordinate their own care. This proposed rule would help patients to focus on their health, enable providers to better coordinate high-quality healthcare, and empower both to achieve improved health outcomes,” said Acting Inspector General Joanne M. Chiedi. “We are proposing strong safeguards to protect patients from fraud and abuse by bad actors who might seek to misuse the new flexibilities.”

Below are examples involving coordinated care, value-based care, data sharing, and patient engagement activities that, depending on the facts, could currently be difficult to fit under existing protections and could potentially be protected by the Stark Law, Anti-Kickback Statute, or Civil Monetary Penalties Law proposals if all applicable conditions are met:

  • In an effort to coordinate care and better manage the care of their shared patients, a specialty physician practice could share data analytics services with a primary care physician practice.
  • Hospitals and physicians could work together in new ways to coordinate care for patients being discharged from the hospital. The hospital might provide the discharged patients’ physicians with care coordinators to ensure patients receive appropriate follow up care, data analytics systems to help physicians ensure that their patients are achieving better health outcomes, and remote monitoring technology to alert physicians or caregivers when a patient needs healthcare intervention to prevent unnecessary ER visits and readmissions.
  • A physician practice could provide smart pillboxes to patients without charge to help them remember to take their medications on time.  The practice could also provide a home health aide to teach the patient and the patient’s caregiver how to use the pillbox.  The pillbox could automatically alert the physician practice and caregiver when a patient misses a dose so they could follow up promptly with the patient.  
  • A local hospital could improve its cybersecurity and the cybersecurity of nearby providers that it works with frequently.  To do so, it could donate, for free, cybersecurity software to each physician that refers patients to its hospital.  The hospital and the physicians often share information about their patients, so it is important that there are no weak links that might compromise everyone else.  The software would help ensure that hackers cannot attack the physician’s computers.  Improving each physician’s cybersecurity would help prevent hackers from spreading the attack to other physicians and the hospital.
  • To improve health outcomes for patients with end-stage kidney disease, a nephrologist, dialysis facility, or other provider could furnish the patients with technology that is capable of monitoring the patient’s health and two-way, real-time interactive communication between the patient, facility, and physician.  In addition, the facility could equip the physicians with data analytics software to help them monitor patients’ health outcomes. 
Read OIG’s proposed rule - PDF.*
Read CMS’s proposed rule - PDF.*
More on the changes to the Stark Law.
More on the changes to the Federal Anti-Kickback Statute - PDF.
* People using assistive technology may not be able to fully access information in this file. For assistance, contact
Source: News




MIPS Data Validation Audits Begin This Month

Beginning this month, CMS will be conducting data validation and audits of a select number of MIPS-eligible clinicians for performance years 2017 and 2018. According to CMS, data validation and audits "are processes that will help ensure MIPS is operating with accurate and useful data."

If your practice is selected, you will receive a request for information from Guidehouse via either certified mail or email. You will have 45 days from the date of the notice to provide the requested information.

CMS currently offers a resource on the criteria for data validation for both performance years 2017 and 2018:

For more CMS resources, visit the QPP Resource Library




MIPS Promoting Interoperability Hardship Exemption

Certified electronic health record technology (CEHRT) is required for participation in the Promoting Interoperability performance category. Under the Merit-based Incentive Payment System (MIPS), you may qualify for a re-weighting of the Promoting Interoperability performance category (to 0%) if you meet certain criteria.
MIPS eligible clinicians, groups, and virtual groups may submit a Promoting Interoperability Hardship Exception Application citing one of the following specified reasons:
  • You're a small practice
  • You have decertified EHR technology
  • You have insufficient Internet connectivity
  • You face extreme and uncontrollable circumstances such as disaster, practice closure, severe financial distress or vendor issues
  • You lack control over the availability of CEHRT
Lacking certified electronic health record technology does not qualify you for hardship exemption.
If you're already exempt from submitting Promoting Interoperability, you don't need to apply for this application.**
The Promoting Interoperability Hardship Exception Application for Performance Year 2019 will open early summer 2019 and close December 31, 2019.
**MIPS eligible clinicians who qualify for automatic reweighting:
  • Ambulatory Surgical Center (ASC)-based MIPS eligible clinicians
  • Hospital-based MIPS eligible clinicians
  • Non-patient facing clinicians
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Physical therapists
  • Occupational therapists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Clinical psychologists
  • Registered dietitian or nutrition professionals
If reporting for MIPS as a group, all MIPS eligible clinicians in the group must qualify for reweighting in order for the Promoting Interoperability performance category score to be reweighted for the group.
Updated 4/8/2019: Groups designated as non-patient facing are not automatically eligible to have their Promoting Interoperability performance category reweighted to 0%. To be designated as a non-patient facing group, 75% of the clinicians in the group must be non-patient facing. This does not fulfill the reweighting requirement for group reporting that, for the Promoting Interoperability performance category, 100% of the MIPS eligible clinicians in the group must qualify individually for reweighting. MIPS eligible clinicians who are identified as non-patient facing and who are reporting as individuals do qualify for automatic reweighting of their Promoting Interoperability performance category.
If you qualify for automatic reweighting, you can still choose to report if you’d like. If you do submit data, we’ll score your performance and weight your Promoting Interoperability performance category at 25% of your MIPS final score.
For more information see the Quality Payment Program website:

Deadline: Submit MIPS performance year 2018 data by April 2

The deadline for submission of performance year 2018 data for the Merit-based Incentive Payment (MIPS) is April 2, 2019 at 8:00 PM, ET
MIPS participants must submit data and receive a minimum of 15 points to avoid a negative payment adjustment in 2020.



Error in MIPS 2019 Payment Adjustment

Centers for Medicare & Medicaid Services recently discovered an error in the implementation of the 2019 Merit-based Incentive Payment System (MIPS) payment adjustment.  This error incorrectly applies payments for Medicare Part B drugs and other non-physician services billed by physicians.
Adjustments to impacted claims will occur in the near future:

  • If CMS overpaid a claim based on this error, you will receive notificaton for the recoupment from your Medicare Administrative Contractor (MAC)

  • If Medicare underpaid a claim, it will be adjusted.

Per Medicare, you do not need to do anything.


Do You Disagree with Your MIPS Feedback?
Request a Targeted Review.


If you participated in the Merit-based Incentive Payment System (MIPS) in 2017, your MIPS final score and performance feedback is available for your review on the Quality Payment Program website. If you believe an error has been made in your 2019 MIPS payment adjustment calculation, you can request a targeted review until September 30. 

For More Information:

Direct questions about your perforamnce feedback or MIPS final score, to the Quality Payment Program at 866-288-8292. (TTY: 877-715-6222) or

Source: CMS MLN Connects, 7/8/18



Alert - Extortion Scam Targeting DEA Registrants


Extortion Scam Targeting DEA Registrants

DEA is aware that registrants are receiving telephone calls and emails by criminals identifying themselves as DEA employees or other law enforcement personnel. The criminals have masked their telephone number on caller id by showing the DEA Registration Support 800 number. Please be aware that a DEA employee would not contact a registrant and demand money or threaten to suspend a registrant’s DEA registration.
If you are contacted by a person purporting to work for DEA and seeking money or threatening to suspend your DEA registration, submit the information through “Extortion Scam Online Reporting” posted on the DEA Diversion Control Division’s website,

Extortion Scam Online Reporting
For more information contact:
Locate DEA Field Office for your area -
Registration Service Center - 1-800-882-9539
Email -


CMS Extends the MIPS 2017 Data Submission Deadline from March 31 to April 3 at 8 PM EDT

If you’re an eligible clinician participating in the Quality Payment Program, you now have until Tuesday, April 3, 2018 at 8 PM EDT to submit your 2017 MIPS performance data. You can submit your 2017 performance data using the new feature on the Quality Payment Program website.

Note: For groups that missed the March 16 CMS Web Interface data submission deadline, it’s not too late to submit your data through another mechanism.


MIPS Reporting Deadlines Fast Approaching: Important Dates to Keep in Mind

Deadlines are fast approaching if you plan to submit data for the 2017 Merit-based Incentive Payment System (MIPS) performance period. Don’t wait until the last minute to submit your data. Submit early and often.
Here are key upcoming dates for MIPS:

  • March 1 - deadline for final claims to be processed for the Quality performance category via your Medicare Administrative Contractors (MACs), including claims adjustments, re-openings, or appeals. The claims data submission fact sheet as well as your MAC can provide you with specific instructions for the Quality Payment Program. Please note that claims reporting is only available for individual eligible clinicians.

  • March 16 at 8 pm ET - deadline for 2017 data submission for groups reporting via the CMS web interface.

March 31 - deadline for 2017 data submission for all other MIPS reporting, including via




Information you need to know about the 835/ERA remittance you received from us in November

Last month, we issued duplicate 835 electronic remittance advice (ERA) to some providers. If you received these duplicate statements, please refer to the latest one dated on or after Nov. 24, which corrected the “reason code” on the previous ERA. This may impact how you billed our members.

If you billed your patients based on the older ERA remittance, sent out during the week of Nov. 13, please re-bill your patients based on the statement dated on or after Nov. 24, if necessary.

If you have questions, please log in to our secure provider website at to view the latest claims processing information for your practice.

Source: 2017 ConnectiCare | 175 Scott Swamp Road | Farmington, CT 06032


HHS OIG Hotline phone number used in scam

The Department of Health and Human Services, Office of the Inspector General (OIG) issued a warning to the public that the HHS OIG Hotline telephone number is being used as part of a national scam. The scammers represent themselves as HHS OIG Hotline employees to attempt to obtain or verify personal information, which can be used to steal money from an individual’s bank account or other fraudulent activity. The OIG does not use the HHS OIG Hotline phone number (1-800-HHS-TIPS/1-800-447-8477) to make outgoing calls and individuals should not answer calls from this number. Those who believe they may have been a victim of the scam should call the Hotline to report it. The OIG reminds the public that it is still safe to call the HHS OIG Hotline to report fraud.


  CMS News

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

CMS awards approximately $100 million to help small practices succeed in the Quality Payment Program

New helpline launched to provide additional support

Today, the Centers for Medicare & Medicaid Services (CMS) awarded approximately $20 million to 11 organizations for the first year of a five-year program to provide on-the-ground training and education about the Quality Payment Program for clinicians in individual or small group practices of 15 clinicians or fewer. CMS intends to invest up to an additional $80 million over the remaining four years.

These local, experienced, community-based organizations will provide hands-on training to help thousands of small practices, especially those that practice in historically under-resourced areas including rural areas, health professional shortage areas, and medically underserved areas. The training and education resources will be available immediately, nationwide, and will be provided at no cost to eligible clinicians and practices.

“Clinicians in small and rural practices are critical to serving the millions of Americans across the nation who rely on Medicare for their health care,” said Dr. Kate Goodrich, CMS Chief Medical Officer and Director of the Center for Clinical Standards and Quality. “Congress, through the bipartisan Medicare Access and CHIP Reauthorization Act, recognized the importance of small practices and rural practices and provided the funding for this assistance, so clinicians in these practices can navigate the new program, while being able to focus on what matters most -- the needs of their patients.”

The selected organizations will provide customized technical assistance to clinicians and practices to help them be successful in the Quality Payment Program. For example, clinicians will receive help choosing and reporting on quality measures, as well as guidance with all aspects of the program, including supporting change management and strategic planning and assessing and optimizing health information technology.

This funding is one part of a multi-level outreach effort to help clinicians understand and provide feedback about the new Quality Payment Program. Through webinars and in-person presentations, thousands have received free training and education from CMS staff since the Quality Payment Program Final Rule was released last October. In addition, through the established Quality Innovation Networks, the Transforming Clinical Practice Initiatives, and the Alternative Payment Model Learning Systems, every clinician in the Quality Payment Program can receive in-person training, including information about the Merit-based Incentive Payment System, as well as the Alternative Payment Model track.

As part of that outreach effort, CMS also launched a new telephone helpline for clinicians seeking assistance with the Quality Payment Program. Clinicians may contact the Quality Payment Program by calling 1-866-288-8292 from 8AM – 8PM EST or emailing

CMS awarded contracts to the following organizations to provide the on-the-ground training and education to small practices:

  • Altarum

  • Georgia Medical Care Foundation (GMCF)

  • HealthCentric

  • Health Services Advisory Group (HSAG)

  • IPRO

  • Network for Regional Healthcare Improvement (NRHI)

  • QSource

  • Qualis

  • Quality Insights (West Virginia Medical Institute)

  • Telligen

  • TMF Health Quality Institute

For more information on the Quality Payment Program, please visit:


Get CMS news at, sign up for CMS news via email and follow CMS on Twitter @CMSgovPress



EHR Meaningful Use Registration and Attestation System is Now Open
CMS has opened its EHR Meaningful Use registration and attestation system, permitting Eligible Providers to register for the 2016 program and attest to meeting program requirements. The EHR reporting period was any continuous 90 days between January 1 and December 31, 2016, and participating Eligible Providers must attest by 11:59 p.m. ET on Feb. 28, 2017 at 11:59 p.m. ET in order to avoid a 2018 payment adjustment.
Eligible Providers participating in the Medicaid Meaningful Use program should refer to their specific state program for attestation information
Michele Krpata, BSW, CPC, CPMA
Compliance Officer, Physician Quality Reporting Analyst


Plans for the Quality Payment Program in 2017: Pick Your Pace

While many of us thought they might delay the January 1, 2017 implementation of the Merit-Based Incentive Program (MIPS), it appears that instead there is a plan for a PACE system.  In response to feedback from providers and specialty organizations regarding MIPS, since the proposal in April 2016, CMS has announced a reduction in the reporting requirements for the first year of the program. CMS intends to allow providers to choose their pace of participation in the Quality Payment Program. The PACE options have been created to ultimately ensure that a negative payment adjustment will not be received in 2019.  Options for participation are as follows:

First Option: Test the Quality Payment Program.
Second Option: Participate for part of the calendar year.
Third Option: Participate for the full calendar year.
Fourth Option: Participate in an Advanced Alternative Payment Model in 2017.

To learn more about each option and read the full CMS article, please visit


CERT Documentation Requirements Made Available by CMS

The CERT Documentation office recently published documentation reference lists based on provider and billing types. The provider and billing types are listed alphabetically, providers can view and print the documentation listing(s). The documentation listings will be updated when changes are approved. If printing, providers should refer to the CERT Provider Website to confirm the current listing. The documents are available in both English and Spanish.
These lists also include medical record documentation that may be needed to support services billed to Medicare. Providers submitting documentation via CD should send the password to; use the CID number in the subject line of your email. Note: There is no need for the provider to encrypt the email. Following this procedure will ensure there is no delay in processing the documentation.
To view the available lists, please visit the CERT Provider Website at
Source: NGSMedicare PartB News: CERT Documentation Request Listings Now Available on the CERT Provider Website



CMS New and Revised Place of Service Codes for Outpatient Hospital Departments

The Centers for Medicare & Medicaid Services (CMS) recently published guidance on the upcoming Place of Service (POS) code set revisions.  Effective January 1, 2016, new POS code 19 for "Off Campus-Outpatient Hospital” will be added and POS code 22 will be revised from “Outpatient Hospital" to "On Campus-Outpatient Hospital." This change differentiates between on-campus and off-campus provider-based hospital departments, easing coordination of benefits, and giving Medicaid and other payers the setting information they require to properly adjudicate cost sharing benefits.
The new codes and related billing requirements are detailed in the CMS MLN Matters article MM9231.



POS 19
Off Campus-Outpatient Hospital

A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

POS 22
On Campus-Outpatient Hospital:

A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.



CMS Provides ICD-10 Claim Submission Guidelines

In a MLN Matters article, the Centers for Medicare & Medicaid Services (CMS) offers claims processing guidance for implementing ICD-10 on Oct. 1, 2015. For claims with dates of service prior to Oct. 1, 2015, providers are instructed to submit claims and other transactions with the appropriate ICD-9 diagnosis code. For claims with dates of service on or after Oct. 1, 2015, these transactions are to be submitted with the appropriate ICD-10 code.
As with ICD-9 codes today providers will still be required to report all characters of a valid ICD-10 code on claims. CMS also states that ICD-10 diagnosis codes have different rules regarding specificity and providers are required to submit the most specific diagnosis codes based upon the information that is available at the time.
To assist practices with the ICD-10 transition, CMS has developed a five-step Quick Start resource.



October 1, 2015 is less than 4 months away. Are you ready for ICD-10?
CMS offers an ICD-10 Medicare Fee-for-Service Provider Resource web page to help providers prepare for the transition to ICD-10 on October 1, 2015.
Videos are available on coding basics, testing, home health, and more,
• ICD-10 Coding Basics
• Coding for ICD-10-CM: More of the Basics
• Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments
• Medicare’s Testing Plan for ICD-10 Success
• Converting the Home Health Prospective Payment System Grouper to ICD-10-CM
• ICD-10: Implementation for Physicians, Partial Code Freeze, and MS-DRG Conversion Project
Click here to visit the ICD-10 Medicare Fee-For-Service Provider Resources  web page for a complete list of Medicare Learning Network® educational materials.
Source: MLN Connect Provider eNews, June 4, 2015



New Modifiers for CMS 2015

Effective January 1, 2015 CMS will be adding 4 new HCPCS modifiers.  Theses modifiers will identify subsets of modifier 59.  For many years CMS has audited claims with 59 and has determined that in many cases it is used incorrectly to bypass NCCI edits.  These new modifiers are an effort to more accurately reflect the circumstances identified by modifier 59.
The new modifiers are:
XE – Separate Encounter.  A Service that is distinct because it occurred during a separate encounter.           
XS - Separate Structure.  A service is distinct because it was performed on a separate organ/structure.
XP – Separate Practitioner.  A service that is distinct because it was performed by a separate practitioner.
XU – Unusual Non-Overlapped Service.  The use of a service that is distinct because it does not overlap usual components of the main service.
CMS will still recognize modifier 59, however they note CPT instructions state that -59 should not be used when a more descriptive modifier is available.  CMS may selectively require the new “X” modifiers for codes they consider at high risk for incorrect billing (i.e. certain NCCI edit pairs may only be payable with the “X” modifier).  CMS also notes that it would be incorrect to use the new “X” modifiers along with -59.
Presently CMS will accept either the 59 or the “X” modifier as correct coding, however they are encouraging providers to begin using the new modifiers quickly.  These modifiers will be valid prior to the 1/1/15 effective date and they are allowing MACs to require them prior to this.
Source: CMS MLN Matters MM8863, CR8863



1. Medicare is conducting Revalidation of information on all providers enrolled with Medicare prior to 03/25/11.  IPMS provides credentialing services, which includes handles this re-enrollment, for many of our clients.

All providers enrolled in Medicare will need to revalidate their enrollment information under the new enrollment screening criteria by 3/25/15.  This revalidation effort applies to those providers that were enrolled prior to March 25, 2011.  Newly enrolled providers and suppliers that submitted their enrollment applications to Medicare/CMS on or after March 25, 2011, are not impacted.  Medicare has begun the revalidation process by sending out notices to providers on a regular basis.  This process will continue until March 23, 2015.  Providers and suppliers must wait to submit the revalidation until after being asked by Medicare to do so.  When a the revalidation letter is received from Medicare, forward it to the individual or department responsible for your credentialing in timely fashion; providers have only 60 days to complete and submit the revalidation application.  If a revalidation application is not received by Medicare within 60 days of request, the provider’s Medicare number is suspended, possibly causing a delay in Medicare payments.  The letter is typically sent to the provider’s practice location.  However, providers who worked or currently are working for more than one employer may have the revalidation letter sent to only one of these locations.  It’s important that anything revalidation related that comes from Medicare be forwarded to your credentialing representative or department.

2. Medicaid is also updating their re-enrollment process and is staging out similar letters to providers.  Formerly re-enrollment happened on a group level, but now letters will go out to providers individually, either to home, office or even to a prior employer (as in the case of CRNA’s, APRN’s, or PA’s).  For providers who work at multiple locations, letters can go to either address and there’s no way to anticipate where.  It’s vital that you forward any such communication that you receive to the individual or department responsible for your credentialing process.

3. Experiencing unexpected suspension of Medicare payments?  Could this be due to lack of timely response to the revalidation letter?  This could occur when a provider is unaware the revalidation letter was sent by Medicare because it was received at a former employer or other current employer address. 

4. Practices looking for experienced and dependable Credentialing Services should contact IPMS’ Marketing and Operations Manager, Melanie Vail at (860) 282-4124 or

Deadline Approaching to Avoid the 2014 eRx Payment Adjustment

The final reporting period available to both individual eligible providers (EP) and group practices participating in the Group Practice Reporting Option (GPRO) is fast approaching. Individual eligible providers and GRPO participants have until June 30, 2013 to successfully report as an electronic prescriber. Eligible providers who fail to demonstrate successful eRx reporting will be subject to a 2% payment adjustment of their 2014 for professional services covered under the Medicare Part B Physician Fee Schedule.

The 2013 eRx Incentive Program 6-month reporting period (January 1, 2013 to June 30, 2013) is the final reporting period available to you if you wish to avoid the 2014 eRx payment adjustment.

Individual EPs and eRx GPRO providers who were not successful electronic prescribers in 2012 can avoid 2014 eRx payment adjustment by meeting specified reporting requirements between January 1, 2013 and June 30, 2013. Below are the 6-month reporting requirements:

  • Individual EPs – 10 eRx events via claims

  • eRx GPRO of 2-24 EPs – 75 eRx events via claims

  • eRx GPRO of 25-99 EPs – 625 eRx events via claims

  • eRx GPRO of 100+ EPs – 2,500 eRx events via claims

Some EPs and GPROs may be automatically excluded from the eRx adjustment penalty. Criteria for automatic exclusions can be found in the  Electronic Prescribing (eRx) Incentive Program: 2014 Payment Adjustment Fact Sheet.

CMS may exempt individual EPs and GPROs in eRx from the 2014 eRx payment adjustment if it is determined that compliance with the requirements for becoming a successful electronic prescriber would result in a significant hardship.. Hardship Exemption Requests MUST be submitted by June 30, 2013. Hardship Exemptions are to be filed using the Quality Net Support Page.

For additional assistance with the eRx program contact the QualityNet Help Desk at 866-288-8912 (TTY 1-877-715-6222) or via The Help Desk is available Monday through Friday from 7am-7pm CT.

Is it important to have an electronic data back-up plan?

There is no dispute when it comes to the importance of protecting patient information. For those few who may not be convinced it is important to protect PHI consider the Health Insurance and Portability Act of 1996 (HIPAA). These Privacy and Security requirements exist to securely protect data containing “protected health information”. Despite privacy and security awareness and efforts on the part of medical providers and institutions, systems have been breached. The primary concern when a breach is detected is identity theft. However, a breach, reported by Bloomberg occurred this summer at a medical practice in Illinois. The intention was never to steal the protected patient health or financial information. Hackers breached the practice’s system changing the password and held it for ransom. Yes, their electronic medical records and e-mail was held hostage. Imagine, your practice or hospital has “upgraded” to electronic health records, ordering, and test results, then without notice is unable to retrieve any patient information.

Also this summer, a report on, discusses a 5 hour computer outage due to human error at a leading supplier of electronic health records to hospitals and providers. The outage, which occurred in July, affected an unspecified number of hospitals that utilize this supplier for remote storage of their medical information.

As far back as June 3, 2009, The Indianapolis Star reported that, Methodist Hospital turned away patients in ambulances, for the first time in its 100-plus history. Because the electronic health records (EHR) system had gone down the day before due to a power surge. The hospital turned back to” paper” and within a day became so overwhelmed ambulances were turned away.

So what is the lesson to be learned? Take system security seriously and always be prepared with a disaster recovery plan, because “disaster” cannot always be forecasted by the weatherman.

IPMS is on Medicare’s 5010 approved entities!










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5th Floor
East Hartford, CT 06108
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     Source: – Publications – New Articles


OIG is Watching…

If you code procedures that can be done in the office as well as hospital outpatient or ASC facilities you should be aware that CMS is looking at claims billed with place of service 11 (office). For the last three years, 2007-2009, the OIG has audited procedures billed with POS 11 and has determined that physicians very often bill these incorrectly. Some of the reasons listed in the OIG reports for the incorrect POS were 

1. Billing staff confused about the definition of physician office or other non-facility location

2. Billing staff was unaware of payment differences for procedures performed outside of the office

3. Data entry errors and

4. Flaws in billing systems that caused all claims to be submitted with non-facility POS.

If your office bills for procedures that can be done in another facility make sure you and your staff are up to date with CMS guidelines and place of service codes. Clearly document the location where any procedure is performed and verify that your billing system is configured to bill claims with the correct POS. Develop office policies to insure compliance and establish procedures for correcting any errors found. In this era of continued and increasing scrutiny by Federal and Third Party Payers it’s in your best interest to stay ahead of the game.

Doreen Clark, CPC
Medical Auditing Specialist

Maintain your Balance!!

In this climate of payer audits, specifically Medicare auditing via the RAC agencies, some physicians are opting to do what they feel is “playing it safe”. Specifically, they are undercoding their E&M services, rationalizing that they will stay under the audit radar by opting to bill lower code levels. Not so fast!! This may have a counterproductive effect. Undercoding not only results in less reimbursements for the provider, but it can also raise red flags due to becoming an outlier in the other direction. When Medicare or other payers apply bell curve surveys, the provider who codes too low will stick out just as much as the one that codes too high. The idea is to not get noticed at all and furthermore, undercoding is just a deterrent to learning the rules that the payers play by. So take the time to learn those rules – they will serve you well in optimizing your reimbursement while at the same time maintaining compliant practices. IPMS Coding and Auditing experts are ready to assist providers who desire to become more audit-proof !

Sharon S. Donelli, CPC, CPMA
Integrated Physicians Management Services
Administrative Officer/Director of Coding & Compliance


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Integrated Physicians Management Services
99 East River Drive
Fifth Floor
East Hartford, CT 06108

Phone: (860) 282-4124
Fax: (860) 282-0170

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HHS Proposes Stark Law and Anti-Kickback Statute Reforms to Support Value-Based and Coordinated Care

Today, the Department of Health and Human Services (HHS) announced proposed changes to modernize and clarify the regulations that interpret the Physician Self-Referral Law (the “Stark Law”) and the Federal    Read More