CMS Pub. 100-22, ch. 2, § 20.2

Reporting Option (GPRO)

(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)

Prior to 2010, the eRx Incentive Program was limited to participating as an individual

eligible professional and the determination of whether an eligible professional is a

successful electronic prescriber was made at the individual professional level, based on

the National Provider Identifier (NPI). No incentive payments were available to a group

practice based on a determination that the group practice, as a whole, was a successful

electronic prescriber. To the extent that individual eligible professionals (based on

individuals’ NPIs) are associated with more than one practice, or Taxpayer Identification

Number (TIN), the determination of whether an eligible professional is a successful

electronic prescriber was made for each unique TIN/NPI combination. Therefore, the

incentive payment amount was calculated for each unique TIN/NPI combination and

payment was made to the holder of the applicable TIN (see §40 below).

As required by the MIPPA, beginning in 2010, group practices, by participating in the

eRx group practice reporting option (GPRO), are eligible to qualify for an eRx incentive

payment based on the determination that the group practice, as a whole, is a successful

electronic prescriber. The criteria for determining whether a group practice is a

successful electronic prescriber and the process for reporting by group practices under the

eRx GPRO are discussed in §60.2 below.

In 2010, for purposes of being able to participate in the eRx Incentive Program under the

eRx GPRO, a “group practice” was defined as a TIN with at least 200 or more individual

eligible professionals (as identified by NPIs) who have reassigned their billing rights to

the TIN.

However, in 2011, with the addition of “GPRO II” described in Chapter 1, § 20.3, the

definition of group practice was expanded to include a TIN with at least 2 or more

individual eligible professionals (as identified by NPIs) who have reassigned their billing

rights to the TIN.

In 2012, the definition of group practice for the eRx Incentive Program was further

modified to mirror the 2012 definition of group practice for the 2012 Physician Quality

Reporting System as described in Chapter 1, § 20.3 of this manual. Therefore, a group

practice was defined as a TIN with at least 25 or more individual eligible professionals

(as identified by NPIs) who have reassigned their billing rights to the TIN. In 2012, the

definition of group practice also includes those groups participating in certain Medicare-approved demonstrations projects or various other CMS programs, under which

Physician Quality Reporting System requirements and incentives have been incorporated,

such as groups participating in the Medicare Shared Savings Program.

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In order to participate in the eRx Incentive Program through the GPRO, including those

groups that are deemed participating in the Physician Quality Reporting System, group

practices must have self-nominated and been selected to participate in the Physician

Quality Reporting System GPRO (see Chapter 1, §20 for information on the requirements

for participation in the Physician Quality Reporting System GPRO). CMS assesses

whether the participation requirements are met by each self-nominated group practice and

notifies group practices of a decision.

As required by section 1848(m)(3)(C)(iii) of the Social Security Act (the Act), an

individual eligible professional who is a member of a group practice selected to

participate in the eRx GPRO for a particular program year is not eligible to separately

earn an eRx incentive payment as an individual eligible professional under that same TIN

(that is, for the same TIN/NPI combination) for that year. Once a group practice (TIN) is

selected to participate in the GPRO for a particular program year, this is the only method

of eRx Incentive Program participation available to the group and all individual NPIs

who bill Medicare under the group’s TIN for that program year.

In addition, the group practice will be assessed for applicability of the payment

adjustment, beginning in 2012, discussed in § 60.2.2 below under the GPRO criteria as

well. Although the determination of whether a GPRO is a successful electronic

prescriber will be analyzed at the TIN level, if group practices elect to participate in the

eRx GPRO for a particular program year and the group practice fails to meeting the

reporting thresholds for reporting its eRx activities (i.e., fails to become a successful

electronic prescriber), each eligible professional who belongs to the group practice will

be subject to the payment adjustment, regardless of whether or not the eligible

professional, as an individual, successfully reports . For example, for purposes of the

2012 payment adjustment, if a group practice consisting of 2 individual eligible

professionals elects to participate in the eRx GPRO under the 2011 eRx GPRO II option,

based on the size of this group practice (which is 2), this group practice must report the

eRx measure via claims on 75 unique events for patients in the denominator of the

measure for services occurring between January 1, 2011 and June 30, 2011. If an eligible

professional within the group practice reports the eRx measure on 25 unique events

during the January 1, 2011 and June 30, 2011 reporting period and the other eligible

professional does so for only 5 unique events , provided a limitation or significant

hardship exemption does not apply to the group practice, the group practice as a whole

(i.e., both individual eligible’s) will be subject to a 1.0% payment adjustment on all their

Medicare Part B PFS allowed charges for covered professional services furnished in

2012. Although the first eligible professional would have successfully reported as an

individual, the entire group practice (i.e., both eligible professionals) will be subject to

the 2012 payment adjustment for failing to reach the reporting threshold of 75 unique

events that was required for groups with 2 eligible professionals.