TO:  Primary Care Providers

A provision of the Affordable Care Act (ACA) 42 CFR 447.400 Primary care services furnished by physicians with a specified specialty or subspecialty requires that at the end of calendar years 2013 and 2014, the Alabama Medicaid Agency must review a statistically valid sample of physicians who received higher payment to verify that they met the following requirements:

1.    They have a specialty or subspecialty designation in family medicine, general internal medicine, or pediatrics that is recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS), or the American Osteopathic Association (AOA) and they actually practice in the areas.  The American Board of Allergy and Immunology (ABAI) is an ABMS-recognized sub-discipline of the American Board of Pediatrics and the American Board of Internal Medicine.  

2.    They are not board certified but are practicing in the field of family medicine, general internal medicine, or pediatrics or a subspecialty under one of these specialties, and 60% of their paid Medicaid procedures billed are for evaluation and management (E&M) codes 99201 through 99499 and VFC administration services. 

Note: To verify if the 60% threshold has been met, the following calculation will be used:

Divide the total volume of E&M codes and vaccine administration codes paid by Medicaid by the total volume of all codes paid by Medicaid. This calculation will be done for each eligible physician individually and not as a group practice. Urinalysis, EKGs, and antibiotic administrations are commonly provided by primary care physicians, Centers for Medicare and Medicaid (CMS) did not include them as primary care services in the numerator when calculating the 60% threshold. Therefore, paid billed codes for ancillary services such as labs, x-rays, injections will cause the percentage threshold to be less.

This letter is to notify you that beginning May 1, 2014, the Alabama Medicaid Agency will be conducting an audit of the calendar year 2013 claims to verify that the above requirements were met.  If the audit reveals the above requirements were not met, the enhanced payment will be subject to recoupment and/or the enhanced payments will be stopped.