PCIP

The Primary care Incentive Payment Program (PCIP) was created by the passage of the Patient Protection and Affordable Care Act in March of 2010. Unlike the EHR Incentive Programs, this incentive does not require providers to purchase any new software or complete additional registration forms, but this incentive is limited to physicians and other clinicians who see patients covered by Medicare, and there are additional eligibility requirements.

Eligibility:

To be eligible for this incentive, a healthcare provider must be…
  • Credentialed as an MD, DO, NP, PA, or certified clinical nurse specialist;
  • A primary care practitioner;
      • Family Medicine, Internal Medicine, Pediatrics, and Geriatrics
  • “Office-based,” which means 60% of your allowed charges under the Medicare Physician Fee Schedule (PFS) over the last 2 years fall within one of the following categories:
      • New and established patient office or other outpatient visits (CPT codes 99201 through 99215);
      • Nursing facility care visits, and domiciliary, rest home, or home care plan oversight services (CPT codes 99304 through 99340); or
      • Patient home visits (CPT codes 99341 through 99350)

Please note that even new physicians/clinicians are eligible to participate as soon as they are licensed. While the two year reporting period still applies generally, it does not bar new primary care physicians from receiving quarterly payments, so long as all other eligibility criteria are met. Moreover, eligibility for all providers is determined on an annual basis. Even if you qualify for this incentive in 2011, it does not necessarily follow that you will be eligible in 2012, because the criteria above must be satisfied anew each year.

Are You Eligible

The Centers for Medicare & Medicaid Services (CMS) has submitted the National Provider Identification (NPI) numbers of eligible providers to all Medicare carriers. (CMS will do this for each year the PCIP incentive is active.) Each Medicare carrier has posted an online tool that will allow you to assess your own eligibility for this incentive. Because they are too numerous to list, please visit your carrier’s site directly and have you NPI# ready. If your NPI is on the list, you are automatically eligible for PCIP payments in the current PCIP payment year.

If you are eligible, you are likely to receive payment without any active undertaking on your part. Remember, it is your responsibility to verify that payments are due to you and are actually received by you.

No Need to Enroll:

The NPIs of qualified primary care physicians and other clinicians are identified by CMS based on an analysis of historical Medicare claims.

Timing of Payment:

These payments will be made quarterly, and will be based on the previous quarter’s claim history.

Payment:

Eligible providers will receive cash payouts equal to 10% of the provider’s Medicare allowed charges for the codes specified above. In other words, the provider would receive 10% of the total amount billed to Medicare (for specified CPT codes) for the previous quarter.

Multiple Carriers, Claims Processors, and/or Practice Sites:

If you deal with multiple claim processing contractors and/or provide service at multiple sites, you need not worry—Medicare combines claims data for each unique NPI across all contractors and practice sites to calculate your eligibility to receive this incentive. However, if you are deemed eligible, you will receive PCIP Payments from the various claims processors you work with instead of one single check. The amount of each payment will vary according to the total dollar amount of eligible primary care services processed by that contractor and associated with the NPI each payment year.

Useful Links: