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Ask Adele: January questions answered by Adele Allison

Wednesday, January 15, 2014   (0 Comments)
Posted by: Joy Ingram
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Ask Adele: January questions answered by Adele Allison

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Adele Allison is the National Director of Government Affairs, SuccessEHS. SuccessEHS is a non-voting member of NWRPCA

Meaningful Use with a low Patient Volume, EHR Certification and Program Penalties


Question:
 Our new nurse practitioner will not be able to attest to Meaningful Use in 2014 for performance 2013 since she'll likely finish off the year maybe seeing 10 patients in less than 30 days. Therefore, her first year of attestation will be in 2015 (or 2014) for 2014 and that will be the 90-day period of Stage 1, correct? Will she always be 2 years behind the doctors?

Answer:
Since you are referencing a nurse practitioner pursuing Meaningful Use (MU), he/she must be participating in the Medicaid EHR Incentive Program since he/she would not qualify for Medicare. Nevertheless, the number of patients seen under the Medicaid MU program is immaterial. Qualification for the Medicaid MU program is based upon a percentage of the overall encounter volume (not number of individual patients or visits) being greater than 30 percent, based upon your state Medicaid's calculation formula. Under no scenario is the qualification based upon a set number of patient encounters – only a percentage being Medicaid linked.

The Stage 1 final rule sets the general threshold per eligible professional (EP) at 30 percent. Pediatricians still qualify with a reduced threshold as low as 20 percent, although their incentive would be reduced by one third if they breach the 30 percent threshold. Additionally, EPs performing more than 50 percent of their services in a FQHC or a RHC are afforded special considerations in the calculation by being able to include "needy" patients.

The look-back period to make this calculation was changed in the Stage 2 final rule to the 12 months preceding the attestation date and is no longer tied to the previous calendar year. The definition of what counts as a Medicaid patient encounter has also changed under Stage 2 to include encounters for anyone enrolled in a Medicaid program, including Medicaid expansion encounters (except stand-alone Title 21 encounters) and those with a zero-pay on claims. This policy shift delivered much needed flexibility in for the overall patient volume calculation.

Today, encounters can be counted in the numerator if the patient is a Medicaid-enrolled individual, regardless of the payment liability and can include CHIP encounters for patients in Title 19 and Title 21 expansion programs. However, as stated above, this does not include separate stand-alone CHIP programs for encounters with patients in Title 21 funded Medicaid expansions.

Remember that volume calculations are performed each year the EP pursues Medicaid MU to qualify the EP for eligibility. Look to your individual state Medicaid agency for any nuances as there is slight variance from state to state.

The other benefit of the Medicaid MU program is that a "buffer" year is built-in allowing for the lion's share of the incentive to be paid before the EP hits full stride in adoption and use of electronic health records (EHR). Unlike Medicare MU that requires Stage 1 measure performance out of the gate, the first year of participation under the Medicaid MU programs requires the EP only Adopt, Implement or Upgrade (AIU) certified EHR technology (CEHRT). The EP does NOT actually have to perform Meaningful Use the first year of participation under Medicaid.

But, certification standards matter greatly. The standards to which the EHR has been tested and certified will determine successful attestation under both the Medicare and Medicaid programs. For CY2013, an EP can qualify for MU having met AIU using 2011 Edition CEHRT. However, any EP performing MU in CY2014 must have CEHRT that meets the 2014 Edition standards as tested and certified by an ONC Authorized Testing and Certification Body (ATCB), regardless of the stage of MU the EP is seeking to perform. There are currently 6 organizations that are ONC ATCBs that perform this testing and certification.

So, let us run through your scenario. If the EP:

  • Only had 10 patient encounters in 2013, but 3 of those 10 encounters were Medicaid related, and
  • He/she has contracted with a 2011 or 2014 Edition CEHRT (satisfies "Adopt"), is implementing a 2011 or 2014 Edition CEHRT (satisfies "Implement"), or upgraded from a non-certified system to a 2011 or 2014 Edition CEHRT (satisfies "Upgrade"), and
  • It is the EP's first year of participation, then
  • He/she would be eligible for year 1 incentives in the amount of $21,250.
  • However, if 2014 is to be the EP's first year of attesting for AIU, he/she would only qualify under the above scenario with 2014 Edition CEHRT.

The second year of the EP's participation in the Medicaid MU program would be the first time he/she would actually perform Stage 1 MU. CY2014 has been given special consideration by CMS as a transitional year for moving from 2011 Edition technology to the more advanced 2014 Edition. Therefore, all participants in the MU programs pursuing compliance in CY2014 – regardless of participation year or stage of MU – will perform a 90-day EHR reporting period. Under Medicaid MU, many states are tying the 90-days to a fiscal quarter (E.g. Jan.-Mar, Apr.-June, etc.), mimicking the Medicare program requirements. Bear in mind that 2014 is the only year that all EPs will have a 90-day EHR reporting period, regardless.

Also, understand that MU is an individual provider entitlement program, not a clinic program. Each EP stands on his/her own achievement and will have 2 years in each stage of MU. Therefore, each EP must be evaluated on their own progress to determine where they are in the MU continuum. So, if you lose a provider who was in their second year of performing MU and replace them with a provider who has never participated in MU, the new provider would perform first year AIU under Medicaid MU and receive $21,250 even though the other clinic providers may be in their second year of Stage 1 and only receive $8,500.

Please also be reminded that in a blog post on Dec. 6, 2013, sister agencies under the U.S. Department of Health and Human Services (HHS) – Centers for Medicare and Medicaid Services (CMS) and the Office of National Coordinator (ONC) – revealed their plans to extend the original timeline for adoption and use of CEHRT under Meaningful Use. The new timeline will extend the roll out past 2015 for the 3 Stages to 2017 (See last month's Ask Adele). However, this was a blog post only and the details related to expanded timelines will have to be fleshed out in a formal rulemaking process. Expect proposed rules to be published in the fall of 2014 with the Stage 3 final rules release during the first two quarters of 2015.

 

 

Question: If a provider is attesting through their EMR and then changes practices and begins using a different EMR, do the stages that they're in follow the provider regardless of where they practice? Meaning, they attest for Stage 2, then change practices and EMR systems – do they start the attestation process all over again with Stage 1 or are they required to continue on at their current stage?

Answer:
You must look to the individual EP to determine where they are in the MU continuum. Under the scenario you just described, the EP would continue with their progress so long as they are using 2014 Edition CEHRT. The product/vendor is immaterial. The only factor for qualification is that the technology meets current federal standards – the 2014 Edition standards today.

 

 

Question: What happens if the new EMR is lesser or more than what the EP had used previously? For example, some hospitals don't have full EMR implemented yet where a provider could attest to everything that is out there if they were eligible to. Would there be a fee put on that provider for not attesting at the level they should be at?

Answer:
If performing MU, the EP must fully meet all required criteria. There is no partial credit. As they say, in for a penny, in for a pound.

Bear in mind that if the EP is dually eligible – meaning he/she treats Medicare beneficiaries on a physician fee schedule (fee-for-service) as well as Medicaid patients – they must pay attention to the legislatively mandated Medicare penalties for non-adoption. There are no penalties for non-adoption under Medicaid. Those EPs who bill Medicare under revenue codes, such as EPs practicing in a Community Health Center (CHC) or a Rural Health Center (RHC), will not be subject to Medicare program penalties.

If dually-eligible and not a meaningful user by 2015, the HITECH statute requires the EP to be subject to a payment adjustment on his/her Medicare reimbursement. The details were more fully defined in the Final Rule for Stage 2. An EP who achieves any MU in CY2013 will have no adjustments in 2015. EPs that register for the Medicare program and attest to Stage 1 (at a minimum) by Oct. 1, 2014 will likewise have no adjustment in 2015. Keeping abreast of MU and maintaining continuous progress in adoption and use of CEHRT is vetted annually thereafter with a 2 year lag between the triggering event and the application of program penalties.

Additionally, the Secretary of HHS created hardship exceptions to the application of MU penalties, namely:

  • Insufficient Broadband or Infrastructure. EPs practicing in a remote area with insufficient access to the Internet for any 90-days from the start of year that is 2 years before the penalty year to July 1st of the year in which the penalty would be applied are eligible. (E.g., Insufficient Internet from Jan. 1, 2014 – Mar. 1, 2014 = no penalty in 2016. However, the EP must have "insurmountable barriers" in getting connectivity.)

  • Newly Practicing EP. EPs just starting out and in practice 2 or less years are eligible for a limited exception. Determinations will be based on Medicare claims and enrollment data.

  • Extreme/Uncontrollable Circumstances. This exception is designed for such issues as natural disasters, bankruptcy, debt restructuring, clinic closure, and when an EHR loses its certification status. An EP would be eligible if:
    • They had previously participated, but faced an extreme and uncontrollable event in the year 2 years preceding the year of penalty application (E.g., In CY2014 for CY2016 penalty application); or,
    • The EP has never participated, but faced extreme and uncontrollable circumstance in the year before the penalty year (E.g., In CY2015 for a CY2016 penalty application).
  • Lack of Ability to Influence Availability of Certified EHR Technology (CEHRT). If the EP practices at multiple locations and does not have control over the availability of CEHRT at one or more of those locations where he/she performed 50 percent or more of his/her patient encounters, an exception may be granted.

  • Lack of face-to-face/Telemedicine Interaction with Patients AND Lack of a need to Follow-up. This is very true for radiologists, pathologists and anesthesiologists inasmuch as they typically do not have face-to-face time with patients or a need to follow-up. Potential disqualifiers would include the billing of E&M codes and care plans that have follow-up with the EP.

  • Primary Specialty Listing in PECOS of Radiology, Anesthesiology or Pathology. PECOS numbers are required for all EPs that bill Medicare services on a physician fee schedule. If the EP is listed in PECOS as a radiologist, pathologist or anesthesiologist within 6 months prior to the penalty year, they will be eligible for a hardship exception. For radiology, there are 3 listings that are specifically eligible: (30) Diagnostic Radiology; (36) Nuclear Medicine; or, (94) Interventional Radiology. Anesthesiologists would need a specialty code of (05) and Pathologists (22). CMS plans to automatically grant a hardship exception for these specialists, meaning the EP would not have to make a manual application (required for the previous, above-noted exceptions). Therefore, if an EP in one of these specialties wishes to pursue MU incentives, he/she would need to "opt out" of this automatic hardship. Information on how to do so has not yet been released by CMS.

EPs must formally apply for hardship exceptions no later than July 1st of the year before the payment adjustment year, except under the PECOS hardship, to avoid Medicare payment adjustments. However, earlier applications for hardship exceptions are encouraged by CMS. Medicaid MU EPs who are dually eligible should be advised that receiving a Medicaid incentive for AUI is NOT deemed having performed meaningful use and the EP would still be subject to the Medicare payment adjustment.

Bear in mind that numerous health reform initiatives use incentives and penalties to drive change. The EHR Incentive Programs, eRx Incentive Program and the Physician Quality Reporting System all feature such "carrots and sticks" aimed at motivating health care providers to embrace transformation. In addition, the CMS value-based payment modifier (as required under the Affordable Care Act) will begin rewarding or penalizing providers for performance, defined as a function of the quality and cost of care, starting in 2015 for select physicians and in 2017 for all physicians. All of these programs are intended to shift the way health care is delivered and compensated in the U.S. from reactive care paid on a fee-for-service basis to proactive care with measured performance driving reimbursement for "value."

While the focus of these federal programs is Medicare, everyone should recognize the wide-sweeping trend this has triggered in the industry. All payers – including Medicaid and private carriers – are seeking to leverage the intent of this legislation to drive their own transformation and become purchasers of value. So, regardless of whether you are directly impacted by Medicare program penalties, stepping up to adopt and use health IT will better position you to deliver quality care to the patients you serve and succeed under health care reform. It is very smart to work through the logistics. All of us – providers, hospitals, patients – are part of a health care community. Gains in aligning care through health IT will have a direct impact on measurable high quality performance and efficiency – trademarks of the Accountable Care Organization and industry value-based purchasing models.

While you may have heard about the various financial rewards and penalties attached to these programs, do you understand how they can impact your practice's revenue? Penalties for not successfully participating in Meaningful Use, physician quality reporting system (PQRS) and e-prescribing chip away at your revenue by themselves, but collectively these penalties could take a significant chunk out of your Medicare reimbursement. If non-adoption continues, these cumulative penalties could ultimately reduce your Medicare revenue by more than seven percent in 2017. If you see Medicare patients reimbursed on a physician fee schedule (PFS) and have not begun participating in PQRS and focusing on quality improvement, your revenue is at risk for further reduction in 2017 based on a 2015 performance period by application of CMS' value-based payment modifier required under the Affordable Care Act.

Potential Adjustments

2013

2014

2015

2016

2017

ePrescribing

-1.5%

-2%




PQRS



-1.5%

-2.0%

-2.0%

EHR Incentive Program



-1.0%

-2.0%

-3.0%

Value Based Modifier



-1.0%

-2.0%

TBD

TOTAL POTENTIAL

-1.5%

-2%

-3.5%?

-6.0%?

-7.0%?

Let's consider how these penalties could impact your practice over a period of four years. Take for example a practice with total annual revenue of $2.5 million and a 20 percent Medicare payer mix. If that practice waited until 2015 to begin participating in Meaningful Use, reporting PQRS measures and electronically prescribing, that practice could lose a total of $60,000 over a four-year period. To see how that breaks down, see the chart below.

 Year

Program

Penalty

Revenue Lost

2013

eRx

-1.5%

$7,500.00

2014

eRx

-2%

$10,000.00

2015

MU

-1%

$5,000.00

2015

PQRS

-1.5%

$7,500.00

2015

VBM

-1.0%

$5,000.00

2016

MU

-2.0%

$10,000.00

2016

PQRS

-2.0%

$10,000.00

2016

VBM

-2.0%

$10,000.00

Total 

$60,000.00

So what can you do now to prevent these cumulative penalties from taking a toll on your bottom line? Start participating in Meaningful Use and PQRS as soon as possible. Begin focusing on quality improvement so you will be positioned for success as the health care industry transitions into value-based reimbursement. Make sure your technology provides an easy manner in which to monitor performance measures, such as through a real-time dashboard, so that corrective action can be taken quickly to make measurable improvements that will impact you future reimbursement.

Please contact membership@nwrpca.org to submit your questions to "Ask Adele."

NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.

 


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