Physician Incentive Plan
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
The plan does not make direct or indirect payments to a participating provider as an inducement to reduce or limit medically necessary services furnished to any particular Medicare member. Indirect payment may include offerings of monetary value (such as stock options or waivers of debt) measured in the present or future.
If a physician incentive plan is negotiated that places a participating provider at substantial financial risk for services that the participating provider does not furnish itself, the plan ensures that all such participating providers at substantial financial risk have either aggregate or per-patient stop-loss protection in accordance with applicable Centers for Medicare & Medicaid Services (CMS) guidelines (42 CFR 422.208 (f); MMCM Chapter 6, Section 80.1). Failure to acquire or maintain appropriate stop-loss protection results in new negotiations to reduce the risk threshold below the maximum limit of 25 percent or termination of the agreement in its entirety.
Primary Care Incentive Payment
The following information applies only to participating physician groups (PPGs).
The Centers for Medicare & Medicaid Services (CMS) provides for an incentive payment for primary care services furnished by eligible nonparticipating providers on or after January 1, 2011, and before January 1, 2016. The 10 percent primary care incentive payment (PCIP) must be paid on either a quarterly basis or with each qualifying claim. For Cal MediConnect providers, these requirements are Medicare-specific and not applicable to Medi-Cal. CMS defines a primary care practitioner as:
- A physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine.
- A nurse practitioner, clinical nurse specialist or physician assistant for whom primary care services accounted for at least 60 percent of the allowed charges under the Physician Fee Schedule (PFS) for the practitioner in a prior period as determined appropriate by the Secretary of Health and Human Services (HHS).
Participating providers delegated for claims processing and payments are required to pay the PCIP to primary care practitioners for services delivered in 2014 when all of the following conditions are met:
- Delegated provider does not have an existing contract with the primary care practitioner (therefore, he or she is nonparticipating).
- Nonparticipating primary care practitioner treats a Medicare member.
- Nonparticipating primary care practitioner is listed in CMS' PCIP eligibility file.
Delegated participating providers are required to compare covered primary care service claims paid to nonparticipating primary care practitioners against the National Provider Identifier (NPI) list from CMS. CPT codes 99201 through 99215, and 99304 through 99350 are eligible for the 10 percent bonus. The list can be accessed on the Health Net provider portal.
Additional information about the PCIP program and the CMS MA Payment Guide for Out-of-Network Payments can be obtained through the CMS website at www.cms.gov.
Calculating PCIP
The incentive payment amount is calculated as a percentage of Medicare Part B allowed charges for primary care services, which is the same formula used by original Medicare. Participating providers delegated for claims processing and payments must pay the PCIP unless the total amount owed is less than one dollar. The plan recommends the PCIP be made within 60 days following the close of a calendar quarter.