Physician Resources

New Version 5010 Testing Readiness Fact Sheet Available

All covered entities under the Health Insurance Portability and Accountability Act (HIPAA) must be ready to implement the Version 5010 transaction standards on January 1, 2012. A critical step to reaching this milestone is testing Version 5010 transactions prior to going live. With less than four months until the transition, it is time to take action, especially on external (Level II) testing. CMS has posted a new fact sheet to help you better understand testing and the steps involved.

External testing with business partners in the new Version 5010 format will ensure that you are able to send and receive compliant transactions prior to the deadline. You should begin testing as soon as possible if you have not already done so. Waiting until the last minute may result in long testing queues, so plan ahead to avoid the rush.  

Here are some suggested steps to take now:

  • Identify the partners you currently conduct transactions with
  • Create a schedule and timeline for external testing with each partner
  • Identify priority partners to conduct testing with if you trade with a large number of business partner.

Keep Up to Date on Version 5010.

Please visit the 5010 website located at for the latest news and resources to help you prepare today. 

 All Medicare Provider and Supplier Payments to be made by Electronic Funds Transfer

Existing regulations at 42 CFR 424.510(e)(1)(2)  require that at the time of enrollment, enrollment change request or revalidation, providers and suppliers that expect to receive payment from Medicare for services provided must also agree to receive Medicare payments through electronic funds transfer (EFT). Section 1104 of the ACA further expands Section 1862 (a) of the Social Security Act by mandating federal payments to providers and suppliers only by electronic means.   As part of CMS’s revalidation efforts, all suppliers and providers who are not currently receiving EFT payments  will be identified, and required to submit the CMS 588 EFT form with the Provider Enrollment Revalidation application.

For more information about provider enrollment revalidation, review the Medicare Learning Network’s Special Edition Article #SE1126, titled “Further Details on the Revalidation of Provider Enrollment Information.”

Reducing Improper Payments, Fighting Fraud, and Curbing Waste and Abuse under the Affordable Care Act

Final Rule Released for the Medicaid Recovery Audit Program

This year the Department of Health and Human Services (HHS) released its final rule for the Medicaid Recovery Audit Program, a key part of the Administration’s initiatives to curb waste, fraud and abuse. Created by the Affordable Care Act, the Medicaid Recovery Audit Program will help states identify and recover improper Medicaid payments. It will be largely self-funded, paying independent auditors a contingency fee out of any improper payments they recover that took place in the previous three years.

The Recovery Audit Contractors (RACs) detect and correct past improper payments. RACs review claims after payments have been made, using both simple, automated review processes and detailed reviews that include medical records. RACs can only go three years back from the date the claim was paid, and are required to employ a staff consisting of nurses, therapists, certified coders, and a physician. Under these expansions, RACs will help identify and recover over and underpayments to providers across Medicare and Medicaid for the first time.

New Resources to Fight Fraud

The Affordable Care Act provides an additional $350 million over 10 years and an annual inflation adjustment to ramp up anti-fraud efforts, including increasing scrutiny of claims before they’ve been paid, investments in sophisticated data analytics, and more “feet on the street” law enforcement agents and others to fight fraud in the health care system.

These efforts build on our recently awarded predictive modeling contract under which CMS is using the kind of technology used by credit card companies to stop fraud. Since June 30th of this year CMS has been using this technology to help identify potentially fraudulent Medicare claims and uncover fraudulent providers and suppliers, flagging both for investigation and referrals to law enforcement. This new tool allows CMS for the first time to use real-time data to spot suspect claims and providers and take action to stop fraudulent payments before they are paid.

These efforts build on the many aspects of the Affordable Care Act that are currently working to bring down waste, fraud and abuse in the health care system. To learn about the many accomplishments the new tools have produced in preventing and fighting waste, fraud and abuse in these programs, see

New Information about the Primary Care Incentive Payment Program’s Special Incentive Remittance

Payments under the Primary Care Incentive Payment Program (PCIP) are often electronic, followed-up with a paper report called the Special Incentive Remittance.  The remittance is detailed, identifying all of the PCIP-eligible services for the previous quarter from which CMS calculated the PCIP bonus payment.  In 2012, the remittance will be modified to include a summary statement, sorted by practitioner and incentive.  Stay tuned for an upcoming Change Request (CR) for more information.

2010 Physician Quality Reporting Initiative (PQRI) Payment Update

 The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that payment of incentives for the 2010 Medicare Physician Quality Reporting Initiative (PQRI) has begun for eligible professionals who met the criteria for successful reporting.  Distribution of 2010 payments 2010 Medicare Physician Quality Reporting Initiative (PQRI) is scheduled to be completed by Fri Sep 30.  

Please note: The program name changed from Physician Quality Reporting Initiative (PQRI) to Physician Quality Reporting System in 2011. 

Effective January 2010, CMS revised the manner in which incentive payment information is communicated to eligible professionals receiving electronic remittance advices. CMS has instructed Medicare contractors to use a new indicator of LE to indicate incentive payments instead of LS. LE will appear on the electronic remit. In an effort to further clarify the type of incentive payment issued (either PQRI or eRx incentive), CMS created a 4-digit code to indicate the type of incentive and reporting year. For the 2010 PQRI incentive payments, the 4-digit code is PQ10. This code will be displayed on the electronic remittance advice along with the LE indicator.  For example, eligible professionals will see LE to indicate an incentive payment, along with PQ10 to identify that payment as the 2010 PQRI incentive payment. Additionally, the paper remittance advice will read, “This is a PQRI incentive payment.”  The year will not be included in the paper remittance.

Who to Contact for Questions?

If you have questions about the status of your PQRI incentive payment (during the distribution timeframe), please contact your Provider Contact Center. The Contact Center Directory is available at, on the CMS website.

The QualityNet Help Desk is available Monday through Friday from 7 am – 7 pm CT at 1-866-288-8912 or via  The help desk can also assist with program and measure-specific questions.

To assist eligible professionals understand their 2010 PQRI Incentive Payments, a guide titled 2010 PQRI Incentive Payments, is posted on the CMS website. 


Accountable Care Organizations (ACO) Resources 

Medicare Data to Calculate Your Primary Service Areas

The Centers for Medicare and Medicaid Services (CMS) has posted to the CMS website Medicare data that allows applicants of the Medicare Shared Savings Program to calculate their share of services in each applicable Primary Service Area (PSA).  To access this data, visit the CMS Shared Savings Program website. For detailed instructions on how to use this data to calculate PSA shares, applicants should refer to the Federal Trade Commission/Department of Justice (FTC/DOJ) Policy Statement.

 March 31, CMS released the long-awaited proposed rules on ACOs. Read CMS’s news release, fact sheet, and AMA’s statement about the proposal.

Summit Focuses on Health Information Technology and ACOs in Pennsylvania    May 27, 2011

Transitioning to Accountable Care: Incremental Payment Reforms to Support Higher Quality, More Affordable Healthcare,” a paper by Harold D. Miller of the Center for Healthcare Quality & Payment Reform

Website on Shared Medical Savings


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