1 MEANINGFUL USE OF CERTIFIED ELECTRONIC HEALTH RECORDS: MEDICARE AND MEDICAID INCENTIVE PAYMENTS Alabama Psychiatric Association March 24, 2011 by: D. Brent Wills, Esq. Kaufman Gilpin McKenzie Thomas Weiss, P.C.
2 1. February 18, 2009 President Obama signed stimulus bill (including HITECH Act) 2. June / July 2010 CMS and ONC established Stage 1 certification / meaningful use requirements 3. Fall 2010 ONC appointed ONC-ATCBs, ONC-ATCBs began certifying EHRs 4. January 1, 2011 Registration began for Medicare incentives programs 5. January 19, 2011 ONC HIT Policy Committee published recommendations for Stage 2 meaningful use requirements 6. April, 2011 EPs may begin attesting to meaningful use for 2011 Medicare incentives Registration will begin for Alabama Medicaid incentives program EPs may begin attesting to acquiring, implementing or upgrading certified EHRs for 2011 Medicaid incentives 7. May 2011 CMS and Alabama will begin paying incentives to EPs 2
3 AND MEDICAID INCENTIVES Medicare Incentives Program vs. Medicaid Incentives Program With respect to physicians and other eligible professionals ( EPs ): Medicare Alabama Medicaid Administrator CMS Alabama Medicaid SMHP (CMS approved) Eligible Professionals Physicians 42 U.S.C. 1395x(r) Includes non-physician providers (e.g., NPs, some PAs) Program Participation Medicare Part B FFS (no volume requirement) Commencement January 1, 2011 (First payments: May 2011) Duration Through 2016 Through 2021 Last Year to Qualify for Incentives Last Date to Qualify for Maximum Incentives October 3, 2012 December 31, 2016 Medicaid patient volumes (defined in SMHP) April 1, 2011 (First payments: May 2011) Initial Qualification First Year: Meaningful Use for 90 days First Year: Acquire, implement, upgrade Second Year: Meaningful use for 90 days Maximums 5 consecutive years / $44,000 total 6 years / $63,750 total Penalties Beginning in 2015 (all Medicare EPs) None Payment Calculation Varies with Medicare patient volume (75% FFS allowable charges) Not based on patient volume 3
4 EPs may qualify for either Medicare or Medicaid incentives in a year, but not both (one switch pre-2015). EPs in a group practice will qualify separately for Medicare or Medicaid incentives (per NPI). EPs may reassign Medicare or Medicaid incentives to one employer / group (one TIN). Single, lump sum payment per year. EPs who already have certified EHRs are eligible Payments are incentives, and not reimbursements similar to a rebate 4
5 1. Requirements to qualify for Medicare / Medicaid Incentives (a) Prerequisites (b) Certified EHR technology - must have EHR that is certified by an ONC-ATCB pursuant to ONC requirements (c) Eligibility must be eligible professional (d) Meaningful Use 2. Payment of Medicare and Medicaid Incentives (a) Medicare Incentives (b) Medicaid Incentives 5
6 1. Requirements to qualify for Medicare / Medicaid Incentives (a) Prerequisites Register (once, not annually) on CMS website will direct Medicaid EPs to Alabama registration site CMS registration: https://www.cms.gov/ehrincentiveprograms/20_registrationandattestation.asp Alabama Medicaid registration: Don t have to be ready for meaningful use; don t need certified EHR National Provider Identifier ( NPI ) User account in National Plan and Provider Enumeration System ( NPPES ) Register with Provider Enrollment Chain and Ownership System ( PECOS ) Medicare only NOTE: Registration for Medicare incentives began January 1. Registration for Medicaid incentives begins April 1. NOTE: Must register not later than two (2) months after end of first payment year. NOTE: Beginning in May, 2011 (but not before), practice managers and other designees 6 may register and attest on behalf of EPs.
7 1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (b) Certified EHR Technology must be certified by ONC- ATCB 6 ONC-ATCBs so far: CCHIT, Drummond Group, InfoGard, SLI Global Solutions, ICSA Labs, Surescripts 400+ certified EHRs; up-to-date list available on ONC website ONC-ATCBs will certify either (i) complete EHR or (ii) combinations of EHR modules 7
8 1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (c) (1) Must be: Eligibility (continued) (i) Eligible Professionals (continued) (A) Medicare Three requirements: Doctor of Medicine Includes Psychiatrists Doctor of Osteopathy Doctor or Oral Medicine Doctor of Podiatry Doctor of Optometry Chiropractor (2) Must participate in (and/or submit patient claims to) Medicare Part B fee-forservice program No volume requirement (3) Must not be hospital based (90%+ ER / inpatient) NOTE: May not simultaneously participate in Medicare e-prescribing. 8
9 AND MEDICAID INCENTIVES 1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (c) Eligibility (continued) (i) Eligible Professionals (continued) (B) Medicaid Three requirements: (1) Must be: Physician Includes Psychiatrists Dentist Nurse Practitioner ( NP ) Certified Nurse Midwife Physician Assistant (only in PA led FQHC / RHC) (2) Must meet one of three patient volume thresholds: (a) Pediatricians 20% Medicaid (b) Work predominantly (50%+ encounters) in FQHC / RHC, and treat 30%+ needy individuals (Medicaid + SCHIP + uncompensated + ability to pay) in that setting (c) All other Medicaid EPs 30% Medicaid (3) 2(a) and 2(c) must not be hospital based NOTE: Alabama SMHP provides specifications to determine patient volumes. NOTE: EPs may meet Medicaid patients volumes based on individual patient encounters or by proxy, using clinic/group encounters 9
10 1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use To demonstrate meaningful use : (i) (ii) Must satisfy all 15 core objectives and measures Must satisfy any five of the remaining menu of 10 objectives and measures (iii) Certain core / menu items may be excluded must meet exclusion criteria (iv) Core objectives include reporting clinical quality measures ( CQMs ) 3 core (or 1 or more of 3 alternative core) + 3 additional CQMs may not exclude CQMs; report zero for inapplicable measures 10
11 1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use (continued) EHR Reporting Periods EPs may qualify for Medicare and Medicaid Incentives by: (1) First payment year (2011 or later year): (i) (ii) Medicare meaningful use for continuous 90-day period Medicaid acquire, implement or upgrade certified EHR (no minimum period) (2) Second payment year: (i) (ii) Medicare meaningful use year-round Medicaid meaningful use for continuous 90-day period (3) Thereafter, meaningful use year-round NOTE: To qualify in 2011 / first payment year (or second payment year, for Medicaid EPs), EPs must begin meaningful use not later than October 2. 11
12 1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use (continued) Reporting / Attestation (1) Payment year To demonstrate meaningful use: (i) Attest to compliance with meaningful use objectives and measures (including CQM) Yes or No Have you done this? Calculation Have you done this / captured this information for a certain percentage of patients? (report numerator, denominator and percentage) (2) Payment year 2012 (and after) - To demonstrate meaningful use: (i) Report CQMs electronically electronic specifications, procedures, etc. t/b/d (ii) Attest to compliance with other meaningful use objectives NOTE: Attest only once per year, at end of reporting period. NOTE: Medicare and Medicaid EPs may attest beginning in April, NOTE: In first payment year, Medicaid EPs must attest only that they have acquired, implemented or upgraded a certified EHR. 12
13 1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use (continued) Core meaningful use objectives: Computerized physician order entry (CPOE) E-Prescribing (erx) Report clinical quality measures to CMS/States Implement one clinical decision support rule Provide patients with an electronic copy of their health information, upon request Provide clinical summaries for patients for each office visit Drug-drug and drug-allergy interaction checks Record demographics Maintain an up-to-date problem list of current and active diagnoses Maintain active medication list Maintain active medication allergy list Record and chart changes in vital signs Record smoking status for patients 13 years or older Capability to exchange key clinical information among providers of care and patient-authorized entities electronically Protect electronic health information NOTE: Corresponding meaningful use measures and applicable exclusions listed in 13 Appendix A1 of outline.
14 1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use (continued) Menu meaningful use objectives: Drug-formulary checks Capture clinical lab test results Generate lists of patients by specific conditions Reminders to patients per patient preference for preventive/follow up care Provide patients with timely electronic access to their health information Use certified EHR technology to identify patient-specific education resources Medication reconciliation Summary of care record for each transition of care/referrals Capability to submit electronic data to immunization registries/systems* Capability to provide electronic syndromic surveillance data to public health agencies* *Must select at least one public health objective. NOTE: Corresponding meaningful use measures and applicable exclusions listed in Appendix A2 of outline. 14
15 1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use (continued) Sample core meaningful use objectives, measures and exclusion criteria: Objective Measure Exclusion Criteria Use CPOE for medication orders directly entered by licensed health care professional who can enter orders into the medical record per state, local and professional standards Implement drug-drug and drugallergy interactionchecks Generate and transmit permissible prescriptions electronically (erx) More than 30% of unique patients with at least one medication in their medication list seen by EP have at least one medication ordered entered using CPOE EP has enabled this functionality for entire EHR reporting period More than 40% of all permissible prescriptions written by EP are transmitted electronically using certified EHR EPs who order less than 100 medications during EHR reporting period None EPs who order less than 100 medications during EHR reporting period 15
16 1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use (continued) Stage 1 core CQMs report all three (3). (1) Record blood pressure for patients with hypertension whom EP saw more than once Not applicable to psychiatrists report zero denominator. (2) Report assessment and cessation intervention for tobacco patients at least once within two years. (3) Record BMI and, if BMI is outside parameters, plan for follow up. May not apply to psychiatrists if not, report zero for denominator. 16
17 1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use (continued) Stage 1 alternative core CQMs may be required to report, if core CQMs don t apply. (1) Weight assessment and counseling for children. Not applicable to psychiatrists report zero denominator. (2) Flu immunization for patients 50+ years old. Not applicable to psychiatrists report zero denominator. (3) Immunization status. Not applicable to psychiatrists report zero denominator. 17
18 1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use (continued) Additional clinical quality measures must report 3 out of 38. The additional CQMs most likely applicable to psychiatrists are: (1) Capture the percentage of patients 18+ years old diagnosed with new episodes of major depression, treated with antidepressants during acute and continuation processes. (2) Capture the percentage of patients 18+ years old whom EP (i) advised to quit smoking; or (ii) discussed cessation medications, methods or strategies. May not be applicable to psychiatrists if not, report zero denominator. (3) Capture the percentage of patients (any age) with new episodes of alcohol / drug dependence who (i) initiate treatment through an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of diagnosis; and (ii) initiate treatment and have two or more additional services with AOD diagnosis within 30 days thereafter. NOTE: If fewer than three apply, (i) report zero as denominator for one (or two, or all, as applicable); and (ii) attest that none of the measures not reported apply. 18
19 1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use (continued) Three stages: First Payment Year Payment Year Stage 1 Stage 1 Stage 2 Stage 2 T/B/D 2012 Stage 1 Stage 1 Stage 2 T/B/D 2013 Stage 1 Stage 2 T/B/D 2014 Stage 1 T/B/D 2015 T/B/D 19
20 2. Payment of Medicare and Medicaid Incentives (i) Medicare (A) May qualify for up to five consecutive years, $44,000 aggregate incentives. (B) Payment = 75% allowed Medicare Part B FFS charges, subject to annual maximums (+10% for HPSA) (C) Based on claims submitted not later than two months after year-end Total $18,000 $12,000 $8,000 $4,000 $2, $44,000 $18,000 $12,000 $8,000 $4,000 $2,000 $44,000 $15,000 $12,000 $8,000 $4,000 $39,000 $12,000 $8,000 $4,000 $24,000 (D) CMS will impose penalties on all Medicare EPs beginning in 2015 (1%, +1% each year, at least through 2017; 3-5% each year thereafter) NOTE: For max Medicare incentives, must begin meaningful use in 2011 or NOTE: CMS anticipates paying Medicare incentives (i) within days after attestation; and (ii) beginning in May,
21 AND MEDICAID INCENTIVES 2. Payment of Medicare and Medicaid Incentives (continued) (ii) Medicaid (A) May qualify for up to six years (consecutive or non-consecutive), $63,750 aggregate incentives, as follows: Total $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750 $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750 $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750 $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750 $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750 $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750 (B) Incentive payments reflect 85% of net average allowable costs (determined by CMS), not actual costs. (C) No penalties NOTE: Pediatricians (with 20-30% Medicaid volume) may only receive 2/3 of the allowable incentives ($42,500 total). NOTE: Alabama Medicaid anticipates paying incentives (i) within 30 days of attestation; and (ii) beginning in May,
22 STAGE 2 MEANINGFUL USE REQUIREMENTS January, 2011 ONC HIT Policy Committee published recommendations for Stage 2 meaningful use requirements: 1. Convert all Stage 1 menu options to core requirements Ex: Drug formulary checks, syndromic surveillance data, lab results 2. Increase thresholds for existing measures Ex: E-prescribing from 40% to 50% CPOE from 30% to 60% and include lab and radiology orders Vital signs from 50% to 80% 3. New measures: Ex: Electronic physician notes Offer downloads of clinical encounter, health record information Ensure patient use of online portal, secure messaging Record patient preference for communication medium Record longitudinal care plans Generate list of care team members 4. CMS to promulgate Stage 2 regulations later in 2011 NOTE: Stage 2 will apply beginning in 2013 and 2014 for established meaningful users. 22
23 IN SUMMARY: LIVING THE (HITECH) DREAM Reduced qualifications (especially for Medicaid) Incentive amounts are per EP Opportunity for group practices? Opportunity to get benefits quickly May receive substantial incentives ($30,000 Medicare, $29,750 Medicaid) by end of 2012 For Medicaid EPs, flexibility Don t have to start till 2016 (when Medicare EPs are paying penalties) to get maximum Medicaid incentives May meet Medicaid patient volume requirements by proxy Flexibility to exclude objectives and measures not relevant to specialties Meaningful use will improve quality, safety and efficiency; reduce disparities; engage patients and families; improve patient care coordination; improve public health Commercial payors, health plans may also provide incentives. No plans yet for BC/BS Alabama, though. 23
24 IN SUMMARY: REALITY CHECK Incentives, not reimbursements Benefits are capped; (potential) costs are not. Medicare EPs lose maximum incentives after 2012, begin paying penalties in 2015 Hurried implementation disrupts work flow, damages morale, etc. Physician resistance, buyer s remorse, vendor disparities / implementation creep Incentive payments subject to: Income tax Offset / recoupment Audit 24
25 IN SUMMARY: WHAT TO DO Talk to your similarly situated colleagues (e.g., same specialty, practice size) best information to evaluate vendors / products, plan for adoption and implementation Talk to EHR vendors, confirm your EHR is ONC certified Talk to your accountant EHRs will substantially impact business operations Talk to your lawyer Vendor reps and warranties, license and purchase terms, your rights and remedies are especially critical Be quick, but don t be in a hurry. John Wooden Plan and budget for implementation Solicit physician / provider buy-in Vet your vendor(s) It s not all about the incentives 25
26 For additional information: CMS https://www.cms.gov/ehrincentiveprograms/ Registration and Attestation - https://www.cms.gov/ehrincentiveprograms/20_registrationandattestation.asp Meaningful Use Measures and Objectives - https://www.cms.gov/ehrincentiveprograms/downloads/ep-mu-toc-core-and- MenuSet-Objectives.pdf Meaningful Use List Serve Alabama Medicaid Registration and Attestation Kim Davis Allen, Alabama Director for Health IT Alabama Health Information Exchange Alabama Regional Extension Center ( AL-REC ) University of South Alabama / (251)
27 Thank You! Any Questions? D. Brent Wills, Esq. Kaufman Gilpin McKenzie Thomas Weiss, P.C. (334)
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