Washington State EHR Incentive Program WHITE PAPER #1: EP Patient Volume Calculations Created April 2011; Updated March 2012

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1 Washington State EHR Incentive Program WHITE PAPER #1: EP Patient Volume Calculations Created April 2011; Updated March 2012 INTRODUCTION: Each year of participation, a Medicaid provider must meet patient volume requirements, as follows: Entity Type Minimum 90-day Medicaid Patient Volume Threshold Or the Medicaid EP Physicians 30% practices Pediatricians 20% predominantly in an Dentists 30% FQHC or RHC, with Certified Nurse Midwives 30% 30% needy Physician Assistants (PAs) practicing individual patient 30% at an FQHC/RHC led a PA volume threshold Nurse Practitioner 30% Acute Care Hospital 10% N/A Children s Hospital No Patient Volume Requirement N/A Per and the discussion in the final rule Section II.D.3.d, from pages to 44491, patient volume is calculated dividing the number of Medicaid encounters during any representative and continuous 90-day period in the preceding calendar year the total number of encounters in that same period. In other words, patient volume is a percentage derived from a fraction with a numerator of Medicaid encounters and a denominator of total encounters. CMS does not believe the tracking of encounters to establish patient volume should be impossible or onerous for providers, seeing as [they] are businesses and there is an expectation that they are tracking their receivables from all entities (including Medicaid) associated with specific patients. That said, CMS also indicates that determining patient volume is not an exact science: We expect providers and States to make estimation in accordance with the methodologies we established here. The estimation would need to be made with reasonable effort, using verifiable data sources the provider and the State. With benchmark data and averages, the State will know only what is reasonable for the denominator value of any given practice. The State will assume that the total encounter (denominator) numbers submitted during application is supported reasonably accurate business data, which can be requested, submitted and reviewed in the event of an audit. From its ProviderOne MMIS system, the State has much more information regarding numerator values, which will be used to validate the numbers submitted participants when they complete their online state application. For purposes of calculating patient volume, only Medicaid (Title XIX) encounters may be counted; CHIP (Title XXI), or encounters funded through other State programs, cannot be included. We realize practices cannot always distinguish between these different funding sources. To overcome this complication, the State is providing a multiplier calculated from statewide data that deducts an estimation of non-medicaid encounters from the general medical assistance totals of the practice. For more information in this regard, please go to the application worksheets at the EHR Incentive Program website.

2 WHITE PAPER #1: EP Patient Volume Calculations Page 2 DETAILS & COMPONENTS: What is an encounter? Patient volume calculations depend upon the definition of encounter. How CMS intends the word and concept to be understood is discussed in the Final Rule, Section II.D.3.d, pages through 44491, where a Medicaid encounter is defined as: Services rendered on any one day to an individual where Medicaid or a Medicaid demonstration project under section 1115 of the Act paid for part or all of the service; or Services rendered on any one day to an individual for where Medicaid or a Medicaid demonstration project under section 1115 of the Act paid all or part of their premiums, copayments, and/or cost-sharing. Encounter under Managed Care or similar structure with capitation or case assignment CMS also allows a calculation meant to capture Medicaid enrollees assigned to an EP s panel within the 90-day period, while also accounting for additional unduplicated Medicaid encounters with patients not on the EP s panel. This calculation is as follows: Numerator = the total Medicaid patients assigned to the EP s panel when at least one Medicaid encounter took place with the Medicaid patient in the year prior to the 90-day period, PLUS any unduplicated Medicaid encounters with non-panel patients that occurred within the 90-day period. Denominator = the total patients assigned to the provider in the same 90-day period with at least one encounter occurring with the patient during the year prior to the 90-day period, PLUS all unduplicated non-panel encounters occurring within that 90-day period. Group Practices CMS is allowing practice- or clinic-level patient volume data as a proxy to establish patient volume, which applies to both Medicaid and needy individual patient volume calculations (see below), but only under the five conditions listed in (h): The clinic or group practice s patient volume is appropriate as a patient volume methodology calculation for the EP There is an auditable data source supporting the clinic s or group practice s patient volume All EPs in the group practice or clinic must use the same methodology for the payment year The clinic or group practice uses the entire practice or clinic s patient volume and does not limit patient volume in any way If an EP works inside and outside of the clinic or practice, then the patient volume calculation includes only those encounters associated with the clinic or group practice, and not the EP s outside encounters. Although the patient volume for the entire practice is used (including patient encounters with non-eps), if the proxy calculation results in 30% Medicaid patient volume, only EPs who see Medicaid patients would be eligible for an incentive payment (see additional information regarding EPs in FQHCs and RHCs, below).

3 DETAILS & COMPONENTS continued: WHITE PAPER #1: EP Patient Volume Calculations Page 3 Group Practices continued: What is a group? o According to CMS, State interpretations of the rule should not result, in the aggregate, in fewer providers becoming eligible, a principle that encourages liberal definitions of clinic, group, and practice. o In Washington State, so long as all five conditions in (h) are met, a group is any consistent, coherent, and reasonable association of EPs who are part of the same healthcare organization, including: The entire organization A subset of the entire organization, like a physical practice site, or the EPs in one city or county or region Most other logical and consistent divisions of EP staff, such as: Dentists, whose encounters may be tracked separately Other specialist groups Other logical alignments, upon approval the State program What is NOT a group? o Random EPs from multiple practice sites, associated only for the purpose of calculating a qualifying patient volume threshold o EPs associated into groups according to inconsistent rationale: site here, specialty there, and region somewhere else o Associations that fluctuate and migrate from one payment year to the next FQHCs and RHCs EPs who provide over 50% of their services in an FQHC or RHC during a six month period are the only EPs who can meet their patient volume threshold using needy individual encounters with non-medicaid patients. For these EPs, a needy patient encounter means services rendered to an individual on any one day where: Medicaid or CHIP (or a Medicaid or CHIP demonstration project approved under section 1115 of the Act) paid for part or all of the service, or paid all or part of the individual s premiums, copayments, or cost-sharing; The services were furnished at no cost; and calculated consistent with (h); or The services were paid for at a reduced cost based on a sliding scale determined the individual s ability to pay. FQHC/RHC Fee-for-Service: Numerator = the EP s total number of needy individual patient encounters, per above description, in any representative and continuous 90-day period in the preceding calendar year Denominator = all patient encounters for the same EP over the same representative and continuous 90-day period

4 DETAILS & COMPONENTS continued: FQHCs and RHCs continued: WHITE PAPER #1: EP Patient Volume Calculations Page 4 FQHC/RHC Managed Care: Numerator = The total (Needy Individual) patients assigned to the provider in any representative continuous 90-day period in the preceding calendar year, with at least one encounter taking place during the year preceding the 90-day period, plus the unduplicated needy individual encounters in the same 90-day period Denominator = The total patients assigned to the provider in that same 90-day period, with at least one encounter taking place during the year preceding the 90-day period plus all unduplicated encounters in the same 90-day period For purposes of calculating needy individual volume, Basic Health clients do not qualify. Border Areas The EHR Final Rule Section II.D.4.g (pages ) discusses multi-state practices in border areas where it may impact patient volume calculations. CMS is not prescriptive in this regard and allows for aggregating encounters across states, allowing flexibility to affected EPs. The Washington, Idaho and Oregon EHR programs are collaborating to establish appropriate datasharing relationships for purposes of validating Medicaid volume tallies across borders. Retaining an Audit Trail All patient volume data and calculations should be supported and documented, for two reasons: first, to be fully prepared for an audit, and second, to identify the specific data sources and document the processes which patient volume was determined. Patient volume thresholds must be established in each year of participation. Federal Regulation: Establishing Patient Volume (a) General rule. A Medicaid provider must annually meet patient volume requirements of , as these requirements are established through the State s SMHP in accordance with the remainder of this section. (b) State option(s) through SMHP. A State must submit through the SMHP the option or options it has selected for measuring patient volume. A State must select the methodology described in either paragraph (c) or paragraph (d) of section (or both methodologies). In addition, or as an alternative, a State may select the methodology described in paragraph (g) of this section. (c) Methodology, patient encounter. (1) EPs. To calculate Medicaid patient volume, an EP must divide: (i) The total Medicaid patient encounters in any representative, continuous 90-day period in the preceding calendar year; (ii) The total patient encounters in the same 90-day period. (2) Eligible hospitals. To calculate Medicaid patient volume, an eligible hospital must divide (i) The total Medicaid encounters in any representative, continuous 90-day period in the preceding fiscal year; (ii) The total encounters in the same 90-day period.

5 WHITE PAPER #1: EP Patient Volume Calculations Page 5 Federal Regulation: Establishing Patient Volume continued (3) Needy individual patient volume. To calculate needy individual patient volume, an EP must divide (i) The total needy individual patient encounters in any representative, continuous 90-day period in the preceding calendar year; (ii) The total patient encounters in the same 90-day period. (d) Methodology, patient panel. (1) EPs. To calculate Medicaid patient volume, an EP must divide: (i) (A) The total Medicaid patients assigned to the EP s panel in any representative, continuous 90-day period in the preceding calendar year when at least one Medicaid encounter took place with the Medicaid patient in the year prior to the 90-day period; plus (B) Unduplicated Medicaid encounters in the same 90-day period; (ii)(a) The total patients assigned to the provider in that same 90-day period with at least one encounter taking place with the patient during the year prior to the 90-day period; plus (B) All unduplicated patient encounters in the same 90-day period. (2) Needy individual patient volume. To calculate needy individual patient volume an EP must divide (i)(a) The total Needy Individual patients assigned to the EP s panel in any representative, continuous 90-day period in the preceding calendar year when at least one Needy Individual encounter took place with the Medicaid patient in the year prior to the 90-day period; plus (B) Unduplicated Needy Individual encounters in the same 90-day period, (ii)(a) The total patients assigned to the provider in that same 90-day period with at least one encounter taking place with the patient during the year prior to the 90-day period, plus (B) All unduplicated patient encounters in the same 90-day period. WHITE PAPER #1: EP Patient Volume Calculations Page 6 Federal Regulation: Establishing Patient Volume continued (f) Exception. A children s hospital is not required to meet Medicaid patient volume requirements. (g) Establishing an alternative methodology. A State may submit to CMS for review and approval through the SMHP an alternative from the options included in paragraphs (c) and (d) of this section, so long as it meets the following requirements: (1) It is submitted consistent with all rules governing the SMHP at (2) Has an auditable data source. (3) Has received input from the relevant stakeholder group. (4) It does not result, in the aggregate, in fewer providers becoming eligible than the methodologies in either paragraphs (c) and (d) of this section. (h) Group practices. Clinics or group practices will be permitted to calculate patient volume at the group practice/ clinic level, but only in accordance with all of the following limitations: (1) The clinic or group practice s patient volume is appropriate as a patient volume methodology calculation for the EP. (2) There is an auditable data source to support the clinic s or group practice s patient volume determination. (3) All EPs in the group practice or clinic must use the same methodology for the payment year. (4) The clinic or group practice uses the entire practice or clinic s patient volume and does not limit patient volume in any way. (5) If an EP works inside and outside of the clinic or practice, then the patient volume calculation includes only those encounters associated with the clinic or group practice, and not the EP s outside encounters.

6 Further Information: Any further questions regarding patient volume calculations or other issues concerning the EHR Incentive Program in Washington State, please contact This White Paper will be updated periodically, as needed.