The eligible provider that stimulus forgot

March 19, 2010

Does HITECH treat MA providers differently than providers that participate with the original Medicare program?

I visited recently with a group of providers in southern California that are preparing to implement a new EHR system. The group is a large multispecialty practice with more than 150 physicians - all eligible professionals in Stimulus-speak - and derives a significant portion of its work and hence a lot of its revenue from treating Medicare patients.

The CIO of the group asked me what they should expect in terms of incentive payments pursuant to the HITECH Act of 2009’s ARRA - and I immediately said, “Well of course your physicians will all be eligible, and likely for the maximum incentive payment of $44,000 per eligible professional over five years.”

He looked at me like I had two heads, and commented that almost all of its Medicare revenue comes from treating Medicare Advantage (MA) participants. Then it hit me: Does HITECH treat MA providers differently than providers that participate with the original Medicare program?

I had to research this - and found to my utter disbelief that the answer is yes. The process to qualify for incentives as a provider to Medicare recipients under several MA contracts is much more stringent than what we’ve come to learn about Medicare eligibility.

You see, if a provider doesn’t generate enough Medicare Allowable Charges (MAC) (from seeing “original” Medicare patients) to garner incentives because of the size and scope of their MA practice, they have to pass the 80-80-20 rule with one MA organization - essentially a commercial insurer that provides covered services to Medicare recipients under a contract with CMS.

In other words, they have to be nearly exclusive with one organization that pays 80 percent of their overall MA payments, perform at least 80 percent of their overall Medicare business with MA patients, and practice in a clinical setting at least 20 hours per week.

So, the MA portion of the incentive really only applies to treating essentially exclusively one MA Organization’s (MAOs) patients. For example, a payer-organization like Kaiser Permanente comes to mind. Never mind that many physicians with MA practices have contracts with multiple MAOs.

One question is why was the bill written this way? Could have been that it was an oversight, so in the rush to get the bill released in February 2009, details were missed or left out. A conspiracy theorist might contend that since the current administration has made no secret of its disdain for the MA program, this slight is just a manifestation of a policy desire.

Nonetheless, it stands that a number of hardworking physicians will be affected by this hole. So what can you do if you’re affected by this? You need to mobilize all available advocacy resources at your disposal to make a collective voice heard that CMS has to develop a methodology that recognizes your standing as a Medicare provider, regardless of the source of your revenue from that program. May the force be with you!