What is E-prescribing?
E-prescribing enables physicians to electronically send an accurate, error-free and understandable prescription directly to a pharmacy from the point-of-care, an element that the Centers for Medicare and Medicaid Services (CMS) says is integral to improving the quality of patient care.

E-prescribing technology includes on-line computerized tools to create and sign prescriptions, perform automated drug safety checks, identify formulary and prescription drug benefits and to help monitor patient medication adherence.

Title 1 of the Medicare Modernization Act of 2003 (MMA) requires drug plans participating in the prescription drug benefit (Part D) to support and comply with electronic prescribing standards. And while E-prescribing is optional for physicians and pharmacies those who choose to E-prescribe covered Part D drugs to enrolled Part D beneficiaries must comply with the E-prescribing standards.

What are the benefits of E-prescribing?
CMS says that E-prescribing can help prevent medication errors by electronically checking dosage, interactions with other medications and therapeutic duplication at the time of prescribing. CMS also believes that E prescribing can improve the quality of care, efficiency, and reduce costs by—

• Actively promoting appropriate drug usage, such as following a medication regimen for a specific condition.
• Providing information about formulary-based drug coverage, including formulary alternatives and co-pay information.
• Speeding up the process of renewing medications by reducing the number of phone calls.
•  Providing instant connectivity between the health care provider, the pharmacy, health plans/PBMs, and other entities, improving the speed and accuracy of prescription dispensing, pharmacy callbacks, renewal requests, eligibility checks, and medication history.
  

Furthermore, CMS says E-prescribing will create efficiencies in the administration of the Part D drug benefit, by facilitating patient eligibility checks, promoting generic drugs and appropriate use, and creating timely interface with formularies. E-prescribing will also improve patient safety by preventing medication errors resulting from illegible handwriting on paper prescriptions.

Where can I read more about E-prescribing?
On November 7, 2005, the Medicare Program; E-prescribing and the Prescription Drug Program; Final Rule was published in the Federal Register. The foundation standards included in this rule applied to all electronic prescribing done under Part D of the MMA. CMS implemented pilot projects to test additional standards in 2006 and as a result of these pilot projects additional standards were published in the Medicare Program; Proposed Standards for E-prescribing Under Medicare Part D; Proposed Rule on November 16, 2007.

On April 7, 2008 the Medicare Program; Standards for E-prescribing Under Medicare Part D and Identification of Backward Compatible Version of Adopted Standard for E-prescribing and the Medicare Prescriptions Drug Program (Version 8.1); Final Rule was published in the Federal Register. The final rule adopts uniform standards for formulary and benefit transactions, medications history transactions, and fill status notifications and provides the following three electronic tools for use in E-prescribing:

• Formulary and benefit transactions: gives prescribers information about which drugs are covered by a Medicare beneficiary's prescription drug benefit plan.
• Medication history transactions: provides prescribers with information about medications a beneficiary is already taking, including those prescribed by other providers, to help reduce the number of adverse drug events.
• Fill Status notifications: allows prescribers to receive an electronic notice from the pharmacy telling them that a patient's prescription has been picked up, not picked up, or has been partially filled, to help monitor medication adherence in patients with chronic conditions.

In a July 21, 2008 Press Release CMS announced their latest effort to encourage physician adoption of E-prescribing by offering incentive payments to physicians and other eligible professionals who use the technology saying that E-prescribing is more efficient and convenient for consumers, improves the quality of care, lowers administrative costs and its widespread use would eliminate thousands of medication errors every year.

In the July press release CMS cites the July 2006 Institute of Medicine (IOM) report, Preventing Medical Errors which said that more than 1.5 million Americans are injured each year by drug errors many of which can be prevented through use of E-prescribing. The Department of Health and Human Services says they expect the use of the technology to save the program as much as $156 million over five years through avoided adverse drug events.

How will physicians be impacted?
Section 132 of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 (H.R. 6331) authorizes CMS to pay an incentive bonus to physicians for successful E-prescribing beginning in 2009 and continuing through 2013. 

For four years beginning in 2009 Medicare will provide incentive payments to eligible professionals who are deemed a successful electronic prescriber. MIPPA of 2008 identifies successful electronic prescribers as those who either report applicable electronic prescribing measures established under the Physician Quality Reporting Initiative (PQRI) or who electronically submit prescriptions under Medicare Part D at a sufficient level as determined by CMS.
Beginning in 2014, bonuses for e-prescribing will be phased out and physicians who haven't adopted E-prescribing will be penalized in the form of reduced Medicare payments. Physicians who have a legitimate reason for not complying may be granted an exception.
Eligible professionals who are successful E-prescribers will receive the following incentive payments:

For 2009 – 2%
For 2010 – 2%
For 2011 – 1%
For 2012 – 1%
For 2013 – 0.5%

Eligible professionals who are not successful E-prescribers face the following reductions in Medicare reimbursement:

For 2012 – 1%
For 2013 – 1.5%
For 2014 & each successive year – 2%

On October 6-7th  in Boston, Massachusetts, CMS held a conference to educate physicians and other stakeholders on the new E-prescribing incentive program. The Medical Group Management Association (MGMA) a proponent of E-prescribing was a cosponsor of the conference. CMS defined the goals of the E-prescribing conference to include:

• Equip healthcare professionals and other stakeholders with the knowledge and the tools to integrate E-prescribing into their business model;
• Educate healthcare professionals about the structure and implementation of the incentive payment structure with respect to E-prescribing and PQRI;
• Generate discussion about the use of E-prescribing and other e-health initiatives to increase patient compliance and overall health outcomes;
• Identify and promote opportunities to overcome barriers to adoption of this new technology; and
• Address constituent concerns about privacy, security and risk management with respect to implementation of the E-prescribing incentive payment program.

What if state laws are in conflict with E-prescribing?
CMS reports that they have identified several categories of State laws that are preempted, in whole or in part, upon the effective date of the final rule, January 1, 2006. The following categories of State laws are unenforceable when they apply to covered Part D drugs that are electronically prescribed for Part D eligible individuals and restrict Medicare’s ability to carry out the e-prescribing program:

• State laws that expressly prohibit electronic prescribing.
• State laws that prohibit the transmission of electronic prescriptions through intermediaries, such as networks and switches or PBMs, or that prohibit access to such prescriptions by plans or their agents or other duly authorized third parties.
• State laws that require certain language to be used, such as dispense as written, to indicate whether generic drugs may or may not be substituted in so far as such language is not consistent with the adopted standards.
• State laws that require handwritten signatures or other handwriting on prescriptions.

CMS Exempts Physicians from DMEPOS Accreditation Requirement for now…

As reported in Volume 4, Issue 2 of the Oplinc Best Practices Review newsletter the Medicare Modernization Act (MMA) of 2003 established the DMEPOS Competitive Bidding Program and section 302(a) (1) of the MMA requires the Secretary to establish and implement quality standards for suppliers of certain items, including consumer service standards, to be applied by recognized independent accreditation organizations.

While physicians and treating practitioners were exempted from having to participate in the competitive bidding program when they provided certain DMEPOS to their own patients they were not exempt from the accreditation requirements.

Physicians and physician organizations have been advocating the physician exemption to the accreditation requirement as the process is time-consuming, expensive and current accreditation requirements are largely impractical for the very small number of items they dispense to their patients.  

Physicians have obtained at least temporary relief from this regulatory burden as Section 154 DELAY IN AND REFORM OF MEDICARE DMEPOS COMPETITIVE ACQUISITION PROGRAM subsection F APPLICATION OF ACCREDITATION REQUIREMENT of the MIPPA contains language that allows CMS to exempt physicians from the DMEPOS accreditation requirement.

This exemption was confirmed by CMS during the September 3, 2008 Special Open Door Forum (ODF) to provide guidance to DMEPOS provider. However, CMS retains the right to establish accreditation standards for physicians in the future…

If you missed this Special Forum an audio recording will be posted to the Special Open Door Forum website at http://www.cms.hhs.gov/OpenDoorForums/05_ODF_SpecialODF.asp and will be accessible for downloading beginning September 10, 2008.

UnitedHealthcare’s Accreditation Requirement Delayed
On August 20, 2008 UnitedHealthcare published an update on their Web site announcing their decision to delay accreditation requirements for physicians and outpatient imaging sites that bill on a 1500 Health Insurance Claim Form or its electronic equivalent. These providers are required to apply to be accredited before being reimbursed for computed tomography, magnetic resonance imaging, positron emission tomography, nuclear medicine, nuclear cardiology, and echocardiography procedures.

Originally the accreditation requirement was to be effective in the third quarter 2008, but in their announcement UnitedHealthcare says the new requirement will not take effect until the fourth quarter of 2009.

Although the program has been delayed UnitedHealthcare advises providers not to delay in taking the necessary steps to become accredited.

UnitedHealthcare identifies diagnostic imaging accreditation programs as a key initiative to advance the quality and safety of imaging studies and emphasizes the need for consumers to receive services from facilities whose equipment, technologists and physicians are in compliance with established accreditation performance standards.

UnitedHealthcare identified the following key factors in their decision for delaying the program stating:

The recent implementation of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires providers of advanced imaging services to be accredited by Jan. 1, 2012. Effective this date, accreditation will become a mandatory requirement in order to receive payment for the technical component of imaging services. We believe it will be beneficial to our network providers to more closely align our reimbursement adjustment timeline with MIPPA.

While the growth in the number of accredited practices is impressive, we have also received feedback that some communities may not have a sufficient number of accredited facilities to meet patient and physician needs.

UnitedHealthcare recognizes the American College of Radiology (ACR) and the Intersocietal Accreditation Commission (IAC) standards.  Specific accreditation guidelines and standards are available on the ACR and IAC Web sites:

American College of Radiology (ACR)
Acr.org
800.770.0145 

Intersocietal Accreditation Commission (IAC)
Intersocietal.org
800. 838.2110

UnitedHealthcare provides the following chart containing the CPT codes that are included in the UnitedHealthcare Imaging Accreditation Program:

Source: www.unitedhealthcareonline.com