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Primary Care First

CMS realizes that Primary Care physicians are not fairly reimbursed as compared to specialists so they have come up with a five-year Medicare pilot program that offers a variety of opportunities to advance care delivery and increase revenue for primary care physicians with Medicare patients that are not enrolled in Medicare Advantage plans.

Primary Care First (PCF) is based on the underlying principles of the CPC+ model design:

  • Prioritizing the doctor-patient relationship
  • Enhancing care for patients with complex chronic needs and high need, seriously ill patients
  • Reducing administrative burden, and focusing financial rewards on improved health outcomes.
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Primary Care First Model Options will be offered in 26 regions for a 2020 start date: Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide).

How will

PCP Benefit?

Practices can increase their revenue by 3 channels:

  • Flat per month / per patient payment
  • Per visit payment
  • Performance-based incentives

How does a primary care provider qualify to participate in the program?

CMS is expected to open the applications in Sept 2019. The primary care provider will need to meet the following criteria:

  • Primary care practitioners need to have an MD, DO, CNS, NP, or PA license in good standing with CMS
  • Provide health services to a minimum of 125 attributed Medicare beneficiaries
  • Have primary care services account for the predominant share (e.g., 70) of the practices’ collective billing based on revenue
  • Demonstrate experience with value-based payment arrangements, such as shared savings, performance-based incentive payments, and alternative to fee-for-service payments
  • Use 2015 Edition Certified Electronic Health Record Technology (CEHRT), support data exchange with other providers and health systems via Application Programming Interface (API), and, if available, connect to their regional health information exchange (HIE)
  • Attest via questions in the Practice Application to a limited set of advanced primary care delivery capabilities, including 24/7 access to a practitioner or nurse call line, and empanelment of patients to a primary care practitioner or care team.

What is the timing for the 2020 PCF launch?

The timing is as follows:

  1. Applications will be accepted sometime in the 2019 summer or early 2019 Fall. The initial deadline of late Spring of 2019 for accepting application was missed by CMS
  2. There will be an 8-week window to apply once CMS starts taking applications
  3. Practices will be selected in the Fall-Winter of 2019
  4. The program will be launched in January 2020
  5. Payments will start being made to participating providers in April 2020.

Is there a cost to apply for PCF?

No there is not. However, looking at the complexity of the application process and to increase your chances of being selected by CMS, you should have a trusted partner who has deep experience with CPC+ program in the past. Integrity Practice Solutions can enroll your practice in this program at no cost and charge you a fee to cover all the administrative tasks required to be in compliance of this program.

Integrity Practice Solutions has over 30 New Jersey practices that increased their revenue through the administration of this CPC+ program several years ago. These practices are available as references and they can speak to the success of Integrity Practice Solution’s experience in administering the CPC+ program.

Is administering the PCF program a billing service function and you can practice keep your current billing function and/or service in place?

No, administrating the PCF program is not a billing service function and yes you can keep your current billing function and/or service. The tasks and skills required to administer the program center around the coordination of care, population management, the delivery of reporting to CMS, the appropriate coding of services such as hierarchical condition category (HCC) coding, and insuring access to the patients.

Can primary care physicians participate in an Accountable Care Organization (ACO) and the Primary Care First (PCF) program?

Yes, primary care physicians can participate in both programs and receive payments from both programs.

We have tried to summarize the PCF program in a short format. We urge you to visit the CMS home page for more information :

https://innovation.cms.gov/initiatives/primary-care-first-model-options/

Why Integrity Practice Solutions?

We are currently working with 30+ delighted practices to administer their CPC+ program and they have reaped the benefits of higher patient satisfaction and significantly improved revenues. We have trained staff who hand hold you all along to help you get selected in by CMS and then successfully administer the program.