Medicare Participation for Calendar Year 2013 

The importance and advantages of being a Medicare participating provider, and we are pleased that the favorable trend of participation continued into 2012 with a participate rate of

96.1 percent, the highest ever. As you plan for 2013 and become familiar with the coming changes, we are hopeful that you will continue to be a participating provider or, if you are non-participating, will consider becoming a participating provider.

As a reminder the following incentive programs are available for Medicare physicians in 2013:

Certain primary care specialties, as authorized by the Affordable Care Act, may receive a 10 percent incentive payment for rendering primary care services;

Electronic health record incentive payments will continue for eligible professionals who demonstrate meaningful use, and;

Eligible professionals will continue to have the opportunity to earn incentive payments for participating in the Physician Quality Reporting System.

Please see below for more specific information regarding these programs.


All physicians, practitioners and suppliers must make their CY 2013 Medicare participation decision by December 31, 2012. Providers who want to maintain their current participation (PAR) status (PAR or Non PAR) do not need to take any action during the upcoming annual participation enrollment program. To sign a participation agreement is to agree to accept assignment for all covered services that you provide to Medicare patients in CY 2013. The overwhelming majority of physicians, practitioners and suppliers have chosen to participate in Medicare. As indicated, during CY 2012,

96.1 percent of all physicians and practitioners are billing under Medicare participation agreements.

If you participate and you bill for services paid under the Medicare physician fee schedule, your

Medicare fee schedule amounts are 5 percent higher than if you do not participate.

In 2013, you will see a continuation of the Medicare program’s emphasis on primary care and important incentive and quality of care initiatives. Our goal of better health and better care at lower costs may be seen through a number of programs, some of which are described below.

Primary Care Incentives

In 2013, CMS will continue to make a 10 percent incentive payment for primary care services furnished by primary care practitioners as authorized by the Affordable Care Act. To be eligible for this incentive payment, a physician’s Medicare specialty needs to be family medicine, geriatric medicine, pediatric medicine, or internal medicine and primary care services needed to constitute 60 percent of Medicare Part B outpatient services (excluding services provided to hospital inpatients or those in emergency departments) in 2011. Nurse practitioners, clinical nurse specialists, and physician assistants are also eligible for these incentive payments. For the first time in 2013, Medicare payments will explicitly reflect the care required to help a patient transition back to the community following a discharge from a hospital or nursing facility. The new codes will recognize the additional resources required by the physician to coordinate a patient’s care following a hospital or nursing facility stay.

Incentives and Payment Adjustments for Quality Reporting

In 2013, eligible professionals (EPs) will have the opportunity to earn incentive payments equal to 0.5 percent of their total allowed Medicare Part B Fee-for-Service charges for services provided during

2013 under both the Physician Quality Reporting System (PQRS) and the Electronic Prescribing (eRx) Incentive Program. Incentive payments earned in 2013 will be paid in CY 2014.

EPs should note that 2013 will also serve as the reporting period for the PQRS payment adjustment that will be applied in 2015. The reporting requirements for the 2015 PQRS payment adjustment are detailed in the 2013 Medicare Physician Fee Schedule (MPFS) Final Rule. Payment adjustments will be applied in CY 2013 and CY 2014 to those EPs who are not successful electronic prescribers under the eRx Incentive Program. EPs can still avoid the 2014 eRx payment adjustment by (1) meeting the reporting requirements for purposes of the 2012 eRx incentive; or (2) reporting the eRx measure on at least 10 unique events from January 1, 2013, through June 30, 2013; or (3) requesting and being granted an exemption due to a significant hardship. CMS expects that EPs will be able to request hardship exemptions via the web in the summer/fall of 2013.