FAQs for AMDA Members on the Medicare and Medicaid Electronic Health Record Incentive Programs, Including Medicare Payment Adjustments

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1 FAQs for AMDA Members on the Medicare and Medicaid Electronic Health Record Incentive Programs, Including Medicare Payment Adjustments Long Term Post-Acute Care Providers I am a physician or nurse practitioner working in long term post-acute care (LTPAC) settings. What electronic health record (EHR) incentives am I eligible for, if any? Physicians may be eligible for either Medicare or Medicaid EHR incentive payments (not both in the same year). Also, while nurse practitioners are not eligible for Medicare EHR incentives, they are eligible for Medicaid EHR incentives. See additional details in the Medicare and Medicaid sections below. Any physician or nurse practitioner whose work is primarily with LTPAC residents should check their eligibility for the Medicaid EHR incentive program. Medicaid EHR incentive payments are generally higher than those available under Medicare and some of the Medicaid eligibility criteria may be less difficult to meet. How do you qualify for Medicaid EHR incentive payments? Generally speaking, more than 30 percent of your patient encounters during any 90 day period in the prior year must involve Medicaid or Medicare/Medicaid (dually eligible) patients. No Medicaid payment is required (important when a State Medicaid allowable for a service is less than 80 percent of the Medicare allowable charge). If you work in a group, you should check to see if you meet the 30 percent threshold as a group. This might allow some members of the group who practice in locations with fewer Medicaid patients to qualify as a member of the group. In addition to the above, more than 10 percent of the encounters must be in a place of service other than inpatient hospital or emergency department settings. Please see additional details regarding eligibility and related matters in the Medicaid section below.

2 What is the amount of Medicaid EHR incentives? Eligible professionals may receive $21,250 in the first year for adopting, implementing, or upgrading certified EHR technology. There is no requirement to demonstrate meaningful use of certified EHR technology in this first year. Eligible professionals may also receive additional payments of $8,500 per year for up to 5 additional years if they demonstrate meaningful use of certified EHR technology; these years do not have to be consecutive. If an eligible professional s Medicaid population falls below the 30 percent threshold, he or she may switch to Medicare EHR incentives but may only do so one time before 2015 (an eligible professional may also switch from Medicare to Medicaid EHR incentives as well). Can eligible professionals employed by a LTPAC facility qualify for EHR incentive payments? Yes. Their employment status does not preclude their receiving EHR incentive payments. How do EHR payment adjustments (penalties) work? Only physicians are subject to EHR payment adjustments for failing to demonstrate meaningful use of certified EHR technology, and the payment adjustments apply only to Medicare, not Medicaid. Nurse practitioners are not subject to these payment adjustments. Hardship exceptions are available and physicians working in LTPAC settings may qualify for them. EHR vendors are in the process of obtaining certification for EHR products intended for use in LTPAC settings and the availability of such certified EHR technology could affect a physician s eligibility for the available hardship exceptions. See the Medicare section below for additional details regarding EHR payment adjustments and related hardship exceptions. Medicare Can physicians receive Medicare payment incentives for adopting electronic health records (EHRs)? Yes. Doctors of medicine and osteopathy are among the eligible professionals (EPs) who may qualify for Medicare payment incentives if they adopt certified EHR technology and meaningfully use such technology (that is, they use the technology to meet certain objectives and other specified requirements). Such EPs may receive up to $44,000 in payment incentives over five consecutive calendar years (10 percent more if they predominantly furnish services in a Health Professional Shortage Area).

3 Note that physicians are considered eligible professionals, not providers, for purposes of the EHR Incentive Program. However, hospitals, one type of Medicare provider, are also eligible for EHR incentive payments. The incentive payments are equal to 75 percent of an EP s Medicare allowed charges up to a maximum annual cap (shown below); as noted, to receive the maximum incentive payment, an EP had to begin participating in the EHR Incentive Program no later than And EPs must become meaningful users of certified EHR technology by 2014 in order to receive any incentive payments. First Calendar Year in which the EP receives an Incentive Payment Calendar Year CY 2011 CY 2012 CY 2013 CY 2014 CY 2015 and later 2011 $18, $12,000 $18, $8,000 $12,000 $15, $4,000 $8,000 $12,000 $12, $2,000 $4,000 $8,000 $8,000 $ $2,000 $4,000 $4,000 $0 Total $44,000 $44,000 $39,000 $24,000 $0 The Centers for Medicare and Medicaid Services (CMS) has lead responsibility for the Medicare EHR Incentive Program and related policies. What are the basic requirements for receiving Medicare EHR payment incentives? A physician or other EP must have 50 percent or more of his or her outpatient encounters during the EHR reporting period at one or more practices or locations equipped with certified EHR technology. The EHR reporting period is the period of time during which an EP must satisfy the applicable meaningful use requirements in order to qualify for EHR payment incentives in a specific payment year it may be as short as a continuous 90-day period or calendar quarter, or as long as a full calendar year, depending on the stage of EHR meaningful use and/or whether the EP is qualifying for an EHR incentive payment for the first time or has previously received one. CMS has indicated that the 50 percent threshold could be met in three ways: Certified EHR technology could be permanently installed at a practice/location; the EP could

4 bring certified EHR technology to the practice/location on a portable computing device; or the EP could access certified EHR technology remotely using computing devices at a practice/location. Prior to 2013, CMS also allowed an EP to create a record of an encounter without using certified EHR technology and then later input the information into certified EHR technology that exists at a different location, but this in no longer permitted. For the purpose of determining whether an EP meets the 50 percent threshold, any encounter where a medical treatment and/or an evaluation and management service is provided should be considered a patient encounter. An EP must also not be hospital-based; a hospital-based EP is one who performs 90 percent or more of his or her covered professional services in an inpatient hospital setting or in the emergency department of a hospital. For Medicare purposes, this determination is made by CMS. An EP must also meet the applicable EHR meaningful use requirements specified by CMS. Stage 1 and Stage 2 meaningful use requirements have been specified (see below), and work has begun on the Stage 3 requirements; the requirements become more challenging from one stage to the next. The table below indicates which meaningful use criteria apply to an EP, depending upon when they first qualify to receive EHR incentive payments. Stage of Meaningful Use Criteria By First Payment Year First Stage of Meaningful Use Payment Year * TBD TBD TBD TBD * TBD TBD TBD TBD * TBD TBD TBD * TBD TBD TBD * 3-month quarter EHR reporting period for Medicare and continuous 90-day EHR reporting period (or 3 months at state option) for Medicaid EPs. All providers in their first year in 2014 use any continuous 90- day EHR reporting period. An EP must register to receive the Medicare EHR incentive payments and subsequently attest to having met the meaningful use requirements. What is certified EHR technology? The Office of the National Coordinator for Health Information Technology (ONC) specifies the standards, implementation specifications, and criteria that EHR technology must meet in order to be certified by ONC-authorized certification bodies. EHR

5 technology may either be certified as a complete EHR or as an EHR module (with a combination of certified EHR modules generally required to meet all EHR meaningful use requirements). At this time, there are two editions of the certification criteria, the 2011 Edition and the 2014 Edition. Beginning in 2014, products certified against the 2014 Edition criteria must be used to achieve meaningful use requirements (products certified against the 2014 Edition criteria may be used in 2013). The full list of certified EHR products, known as the Certified HIT Products List (CHPL), can be accessed at What meaningful use requirements must an EP meet to qualify for EHR incentive payments? Under Stage 1, an EP must meet 15 core objectives and 5 of 10 menu set objectives (or qualify for exclusion from one or more of the required objectives). The core objectives require EPs to do the following: 1. Use computerized physician order entry for medication orders; 2. Implement drug-drug and drug-allergy interaction checks; 3. Generate and transmit permissible prescriptions electronically;* 4. Record demographics; 5. Maintain an up-to-date problem list; 6. Maintain an active medication list; 7. Maintain an active medication allergy list; 8. Record and chart changes in vital signs; 9. Record smoking status for patients 13 years old or older; 10. Implement one clinical decision support rule; 11. Report ambulatory clinical quality measures (in most cases, 3 CMS-specified core or alternate core measures and three additional measures from a CMSadopted menu); 12. Provide patients with an electronic copy of their health information, upon request; 13. Provide clinical summaries for patients for each office visit; 14. Have the capability to exchange key clinical information among providers of care and patient authorized entities electronically; and 15. Protect electronic health information through the implementation of appropriate technical capabilities. * Generally speaking, core measure #3 is the hurdle that prevents long-term post-acute care (LTPAC) providers from achieving meaningful use. Medication orders are entered through the LTPAC facility/pharmacy system, which is not certified EHR technology. The physician would have to copy these orders and re-enter them into their certified EHR and then transmit to the pharmacy.

6 The Stage 1 menu set objectives require EPs to do any 5 of the following 10: 1. Implement drug-formulary checks; 2. Incorporate clinical lab-test results into certified EHR technology as structured data; 3. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach; 4. Send reminders to patients per patient preferences for preventive/follow up care; 5. Provide patients with timely electronic access to their health information; 6. Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate; 7. Perform medication reconciliation when receiving a patient from another setting or provider of care; 8. Provide a summary of care record for patients transitioned to another setting or referred to another provider of care; 9. Submit electronic data to immunization registries; and 10. Submit electronic syndromic surveillance data to public health agencies. For the above core and menu set objectives, CMS has specified applicable measures, numerators and denominators (for percentage-based measures), minimum performance thresholds, and exclusions that may obviate EP compliance with a measure under certain circumstances. CMS has also provided much additional guidance. Under Stage 2, EPs must meet, or qualify for exclusion from, 17 core objectives and 3 of 6 menu set objectives, and report 9 clinical quality measures (from a menu of 64 measures adopted by CMS). For an EP s first payment year under the Medicare EHR Incentive Program, an EP must satisfy the meaningful use requirements for 90 consecutive days. In subsequent years (except 2014), an EP must satisfy the applicable requirements for a full calendar year. If an EP s first year under Stage 2 falls in 2014, he or she will need to demonstrate meaningful use of certified EHR technology during any 3-month calendar quarter in that year. Will physicians be penalized if they do not meet EHR meaningful use requirements? Yes, beginning in calendar year Note, however, that the 2015 Medicare payment adjustment will generally be based on physician performance during calendar year 2013 (a special rule will apply to EPs who have never successfully attested to EHR meaningful use in the past, under which they will be allowed to do so during any continuous 90-day period in 2014 ending no later than September 30, 2014). Similarly, payment adjustments in future years will also be based on physician performance in an

7 earlier period. Physicians failing to meet EHR meaningful use requirements during a relevant reporting period will incur Medicare payment adjustments (reductions) of 1 percent in 2015, 2 percent in 2016, 3 percent in 2017, and up to 5 percent in subsequent years, unless they qualify for one of the available hardship exceptions (see below). Are there any hardship exceptions that allow physicians to escape Medicare payment adjustments for failing to become meaningful users of certified EHR technology? Yes. First, hospital-based physicians (those performing 90 percent or more of their services in an inpatient hospital setting or emergency department) are not subject to EHR payment adjustments. In addition, hardship exceptions are currently available under any one of the following five circumstances (EPs generally must apply to obtain an exception): 1. EPs who practice in areas (whether urban or rural) without sufficient internet access (can be demonstrated for any 90-day continuous period between the start of the year 2 years prior to the payment adjustment year and through the application submission date of July 1 of the year prior to the payment adjustment year); 2. New EPs for 2 years after they begin practicing (an EP who switches specialties and begins practicing under a new specialty will not be considered newly practicing for this exception); 3. Extreme circumstances, including a practice being closed down, a natural disaster in which an EHR system is destroyed, an EHR vendor going out of business, an EP whose certified EHR technology loses its certification either through revocation or because the vendor did not upgrade their certified EHR technology to the latest requirements, or an EP suffering severe financial distress resulting in a bankruptcy or restructuring of debt; 4. EPs who lack both face-to-face/telemedicine interactions with patients and the need to follow up with patients, such as the specialties of anesthesiology, radiology, and pathology; and 5. EPs who practice in multiple locations (for example, surgeons using ambulatory surgery centers or physicians treating patients in nursing homes) where the lack of control over whether certified EHR technology is available at these locations exists for 50 percent or more of their outpatient encounters at such locations (but only if such locations have not adopted certified EHR technology). All exceptions are available for a maximum of five years and generally require submission of an application and supporting information (EPs whose primary specialty

8 is listed as anesthesiology, radiology or pathology will be deemed to qualify for exception #4 and will not need to apply). Are nursing homes eligible for Medicare EHR incentive payments? No. Only hospitals, critical access hospitals, physicians and other eligible professionals (and certain Medicare Advantage organizations for their affiliated hospitals and EPs) currently qualify for Medicare EHR incentive payments. Under Medicare, EPs may assign their incentive payments to their employer or an entity with which they have a contractual arrangement. Where can physicians obtain technical assistance regarding EHRs? The Federal government is funding regional extension centers (RECs) to help providers, especially primary care physicians in small practices, adopt and meaningfully use EHR technology. REC services include outreach and education, EHR support (such as working with vendors, or helping providers choose a certified EHR system), and technical assistance in implementing health IT and using it in a meaningful way to improve care. To find the nearest regional extension center, go to and enter your practice s zip code. Where can physicians get additional information regarding the Medicare EHR Incentive Program and related matters, including payment adjustments? An introduction to the Medicare EHR Incentive Program for eligible professionals is available at Guidance/Legislation/EHRIncentivePrograms/Downloads/Beginners_Guide.pdf. Lots of additional information can be obtained from the official web site for the Medicare and Medicaid EHR Incentive Programs, Guidance/Legislation/EHRIncentivePrograms/Getting_Started.html. Medicaid Can physicians receive Medicaid payment incentives for adopting electronic health records (EHRs)? Yes. Physicians and other EPs can receive up to $63,750 in Medicaid EHR incentive payments across 6 years of participation, generally $21,250 in the first year and $8,500 annually thereafter (the 6 years need not be consecutive but must occur over the period, and the first payment year must occur by 2016). In the first payment year (that is, any year between 2011 and 2016), they can receive an incentive payment for adopting, implementing, or upgrading certified EHR technology (they need not demonstrate meaningful use of the certified EHR technology during this first year). In all

9 remaining years, they must meet essentially the same meaningful use requirements applicable under the Medicare EHR Incentive Program. What are the basic requirements for receiving Medicaid EHR incentive payments? First, the state or territory in which the physician or other EP practices must have an active Medicaid EHR Incentive Program. State-specific information is available at including relevant state web sites, state contacts, program launch dates, and other details. Second, an EP generally must have at least 30 percent of all patient encounters attributable to Medicaid (which includes the Children s Health Insurance Program if offered as part of a Medicaid expansion under either Title XIX or Title XXI of the Social Security Act) over any continuous, representative 90-day period in the most recent calendar year. Patients eligible for both Medicare and Medicaid (dual eligibles) count as Medicaid patients for this purpose. No Medicaid payment is required but the State Medicaid program must list the patient on a remittance advice (e.g., zero payment) to be included. There are two exceptions to the 30 percent threshold: A pediatrician may have 20 percent or more (rather than 30 percent or more) of his or her patient encounters attributable to Medicaid (but pediatricians with a Medicaid volume below 30 percent receive lower EHR incentive payments). EPs practicing predominantly in a Federally Qualified Health Center or a rural health clinic must have a minimum of 30 percent patient volume attributable to needy individuals, which include individuals covered under Medicaid or the Children s Health Insurance Program, those receiving uncompensated care, or those receiving care at no cost or on a sliding scale, based on ability to pay. In a final rule published September 4, 2012, CMS specified that a patient encounter can be counted toward the minimum Medicaid volume threshold if the patient is enrolled in the state s Medicaid program (either fee-for-service or managed care) at the time of service (without the requirement of Medicaid payment liability). Thus, for example, services to a Medicaid-enrolled patient that might not be reimbursed by Medicaid may be included in the Medicaid patient volume calculation. As with Medicare EHR incentives, certified EHR technology must be available in the practice(s) or other location(s) where an EP has 50 percent or more of his or her outpatient encounters during the EHR reporting period, and the EP must not be considered hospital-based. The EP can adopt, implement, or upgrade certified EHR technology in the first year and must demonstrate meaningful use of certified EHR technology in subsequent years. As noted earlier, meaningful use requirements, including applicable reporting periods,

10 generally mirror those under Medicare, although States may seek CMS approval to add or modify certain objectives. If an EP adopts, implements or upgrades certified EHR technology in the first year of payment, the EHR reporting period for the second year (during which EHR meaningful use must be demonstrated) is any continuous 90-day period during that second calendar year. Finally, an EP must register to receive the Medicaid EHR incentive payments and ultimately attest to having met the relevant requirements (adopting, implementing or upgrading certified EHR technology, or meaningfully using such technology, as the case may be). Can physicians receive both Medicare and Medicaid EHR incentive payments? Not for the same year. If an EP meets the requirements of both programs, he or she must choose to receive an EHR incentive payment under either the Medicare or the Medicaid incentive program. After a payment has been made, an EP may only switch programs once before Generally speaking, an EP meeting the requirements of both programs would receive higher payments under the Medicaid EHR Incentive Program. Will there be Medicaid payment adjustments (penalties) for failure to meet EHR meaningful use requirements? No. Payment adjustments for failure to meet EHR meaningful use requirements apply only under Medicare. Are nursing homes eligible for Medicaid EHR incentive payments? No. Only acute care hospitals (which include critical access and cancer hospitals), children s hospitals, physicians and other eligible professionals currently qualify for Medicaid EHR incentive payments. Physicians and nurse practitioners working in nursing home are eligible if they meet applicable requirements. Under Medicaid, EPs may choose to assign their incentive payments to their employer or other statedesignated entities. This assignment is voluntary and requires adequate documentation. Where can physicians get additional information regarding the Medicaid EHR payment incentives and related matters? An introduction to the Medicaid EHR Incentive Program for eligible professionals is available at Guidance/Legislation/EHRIncentivePrograms/Downloads/EHR_Medicaid_Guide_Reme diated_2012.pdf. Lots of additional information can be obtained from the official web site for the Medicare and Medicaid EHR Incentive Programs,

11 Guidance/Legislation/EHRIncentivePrograms/Getting_Started.html. Important EHR Incentive Program Dates February 28, 2013 Deadline for completing EHR meaningful use attestation for physicians participating in the 2012 Medicare EHR Incentive Program October 3, 2013 Last day for eligible professionals to begin a 90-day reporting period for CY 2013 July 1, 2014 Deadline for submitting exception requests for the CY 2015 EHR payment adjustment; CMS to provide additional guidance on the process

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