IV  provides additional detail on the annual and total incentive payments an  eligible provider could receive from the EHR Program based on the initial  year the provider receives an incentive payment.) CMS Analyzed Medicare Part B Claims to Pay Electronic Prescribing Program Incentive Payments to about 8 Percent of Certain Medicare Providers for 2009

To determine which providers should receive the Electronic Prescribing  Program’s incentive payments, CMS analyzes information reported by  providers on their Medicare Part B claims, which are used to submit  charges for covered services. Specifically, for  2009, CMS first examined 2009 Part B claims to determine whether, after  each applicable patient visit, providers marked any one of three electronic  prescribing reporting codes used to report information on the adoption  and use of electronic prescribing systems. Second, CMS analyzed the 2009 Part B claims to determine which of the  providers who submitted the electronic prescribing reporting codes also  met or exceeded both components of the following reporting  requirement:  the provider submitted one of the three electronic prescribing reporting  codes at least 50 percent of the time that the provider had an applicable  visit; and   at least 10 percent of the provider’s total allowed Medicare Part B charges  for the year were from the services designated as applicable patient visits. From 2012 through 2014, the Electronic Prescribing Program will assess  penalties on individual providers and group practices that do not adopt  and use electronic prescribing. CMS  officials expect that the number of Medicare providers reporting the  electronic prescribing reporting code in 2010 will increase over 2009 and  noted that lowering the reporting requirement for 2010 to submitting the  applicable electronic prescribing reporting code for at least 25 visits may  increase the number of providers receiving incentive payments. The EHR Program provides incentives from 2011 to  2016 and introduces penalties beginning in 2015, while the Electronic  Prescribing Program provides incentives from 2009 to 2013 and introduces  penalties beginning in 2012. The EHR Program requires providers to adopt  certified EHR technology and the Electronic Prescribing Program requires  providers to adopt qualified electronic prescribing systems. To help encourage the adoption of  such technologies among Medicare providers, Congress first established  the Electronic Prescribing Program and then the EHR Program, both of  which provide incentive payments to eligible providers that adopt and use  the appropriate health information technologies and impose penalties on  those eligible providers that fail to do so. Despite both programs having a goal to expand the adoption and use of  health information technologies by health providers, and in particular,  physicians—the largest and only group of providers eligible to earn  incentive payments in both programs—we found inconsistencies in the  requirements. First, we found that because the Electronic Prescribing Program lacks a  certification process like that established for the EHR Program, physicians  and other health care providers who want to obtain incentive payments or  avoid penalties from the former program have no assurance that the  systems they invest in will meet that program’s technology requirements. Second,  we also found that the two programs have established separate reporting  requirements related to electronic prescribing, requiring some physicians  who elect to report to the EHR Program to report to both programs in  2011 and potentially requiring physicians to report to both programs  through 2014, when penalties for the Electronic Prescribing Program end. CMS recognizes that this duplication places additional burden on  physicians, and we believe this duplication could affect the decision of  physicians to adopt and use health information technology. However, CMS  is still in the process of studying possible ways to address this duplication,  and if the agency wants to eliminate the burden for providers in 2012, it  would need to do so during its 2011 rulemaking. Expedite efforts to remove the overlap in reporting requirements for  physicians who may be eligible for incentive payments or subject to  penalties under both the Electronic Prescribing and EHR Programs by, for  example, aligning the reporting requirements so that successfully  qualifying for incentive payments or for avoiding penalties under the EHR  Program would likewise result in meeting the requirements for the  Electronic Prescribing Program. CMS agreed in full with two  recommendations, agreed in principle with one recommendation, and  disagreed with a fourth recommendation.
Why GAO Did This Study

Congress established two CMS-administered programs--the Electronic Prescribing Program and the Electronic Health Records (EHR) Program--that provide incentive payments to eligible Medicare providers who adopt and use health information technology, and penalties for those who do not. The Medicare Improvements for Patients and Providers Act of 2008 required GAO to report on the Electronic Prescribing Program. To do so, GAO examined how CMS determines which providers receive incentive payments and avoid penalties from that program and how many providers received incentive payments in 2009. Also, GAO was asked to examine how the requirements of the two programs compare. GAO reviewed relevant laws and regulations, interviewed CMS officials, and analyzed CMS data on incentive payments made for 2009, which were the most recent data available for a full year.

What GAO Found

CMS analyzes information reported by eligible providers on their Medicare Part B claims--which are used to submit charges for covered services--to determine which Medicare providers should receive Electronic Prescribing Program incentive payments or be subject to penalties. In 2009--the first year the program provided incentive payments--CMS paid approximately $148 million in incentive payments to about 8 percent of the approximately 600,000 Medicare providers who had an applicable patient visit--that is, supplied 1 of 33 CMS-designated services typically provided in the office or outpatient setting. For 2009, CMS examined Part B claims to determine whether, after each applicable patient visit, providers marked any one of three electronic prescribing reporting codes used to report information on the adoption and use of electronic prescribing systems. To receive an incentive payment that year, the provider had to report the codes for at least 50 percent of applicable patient visits, and at least 10 percent of the provider's total allowed Medicare Part B charges for the year had to be from the applicable patient visits. CMS made changes in the reporting requirements for 2010. For example, the agency reduced the number of reporting codes to one and required that individual providers report the code after at least 25 applicable visits, instead of for 50 percent of applicable visits. From 2012 through 2014, the Electronic Prescribing Program will assess penalties on providers that do not adopt and use electronic prescribing. Individual providers will have to submit the electronic prescribing reporting code at least 10 times in the first 6 months of 2011 to avoid penalties in 2012. Although GAO found similarities in the technology and reporting requirements for both programs, GAO also found that the requirements of the two programs are inconsistent in several areas. The EHR Program provides incentives from 2011 to 2016 and introduces penalties beginning in 2015, while the Electronic Prescribing Program provides incentives from 2009 to 2013 and provides for penalties from 2012 to 2014, when the program ends. Both the EHR and Electronic Prescribing Programs require providers to adopt and use technology that can perform similar electronic prescribing-related activities. However, the EHR Program requires providers to adopt and use certified EHR systems that meet criteria established by HHS, which include electronic prescribing-related capabilities, while the Electronic Prescribing Program does not have a certification requirement. As a result, providers have no assurance that the systems they invest in will meet the Electronic Prescribing Program's requirements. Additionally, the two programs have established separate reporting requirements related to electronic prescribing, potentially requiring physicians--the largest and only group of providers eligible to earn incentive payments in both programs--to report to both programs from 2011 through 2014. CMS recognizes that this duplication places additional burden on physicians; however, CMS is still in the process of developing a strategy to address this duplication.

What GAO Recommends

GAO is recommending that the CMS Administrator take four actions, including (1) encourage physicians and other providers in the Electronic Prescribing Program to adopt certified technology and (2) expedite efforts to remove the overlap in reporting requirements for physicians who may be eligible for incentive payments or subject to penalties under both programs. CMS generally agreed with three recommendations and disagreed with a fourth recommendation, which GAO clarified based on CMS's comments.