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Primary Care First: Applications Now Being Accepted

By Elizabeth Woodcock, MBA, FACMPE, CPC

November, 2019


Primary care physicians in Arkansas, Tennessee, Virginia, and 23 other states are invited to apply for Primary Care First, the latest payment model by the Centers for Medicare & Medicaid Services (CMS). Applications are accepted from practices that meet certain basic criteria, like having an electronic health record. Not only are the conditions standard, but the patient count need only be a minimum of 125 Medicare beneficiaries. Patients can voluntarily select you in MyMedicare.gov; in addition, CMS uses claims-based data to determine beneficiary attribution. The program is open to physicians in internal medicine, general medicine, geriatric medicine, family medicine, and/or hospice and palliative medicine.

The payment is provided on a “per patient-per month” (PMPM) basis, in addition to a flat primary care visit fee of $50. The PMPM payments fall into five tiers based on acuity, ranging from $24 to $175 per month. These fees are in addition to the visit fee, although it is notable that CMS is placing a small portion – 10% - of the payment at risk. For the first year, the adjustment is made based on hospital utilization. Thereafter, there are five “Quality Gateway” measures for comparison; these include a standard patient experience survey, A1c, controlling high blood pressure, advance care plan, and colorectal cancer screening. Although 10% is at risk, there is a 50% upward “continuous improvement” adjustment should performance be favorable. Dubbed the “Seriously Ill Population,” there is special consideration for Medicare beneficiaries in hospice and palliative care, with $275 allocated for the monthly payment, in addition to an initial fee of $325.

The application process, which opened on October 24, closes on January 22, 2020. The application may be found here.

About The Author

Elizabeth Woodcock is the founder and principal of Woodcock & Associates. She has focused on medical group operations and revenue cycle management for more than 20 years and has led educational sessions for the Medical Group Management Association, the American Congress of Obstetricians & Gynecologists, and the American Medical Association. She has authored and co-authored many books. She is frequently published and quoted in national publications including The Wall Street Journal, Family Practice Management, MGMA Connexion, and American Medical News. Elizabeth is a Fellow in the American College of Medical Practice Executives and a Certified Professional Coder. In addition to a Bachelor of Arts from Duke University, she completed a Master of Business Administration in healthcare management from The Wharton School of Business of the University of Pennsylvania.

The contents of The Sentinel are intended for educational/informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and/or change over time.

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