Stage 2 Regulations: Patient Volume Changes Tip Sheet January 2013 Overview On September 4, 2012, the Centers for Medicare & Medicaid (CMS) published a final rule (Federal Register Volume 77, No. 171 1 ) that specifies the Meaningful Use (MU) Stage 2 criteria that eligible professionals (EPs), eligible hospitals (EHs), and critical access hospitals must meet to participate in the Medicare & Medicaid Electronic Health Record (EHR) Incentive Program. The overall goal of this program is to support and assist increasing numbers of providers to adopt, implement or upgrade (AIU) certified electronic health record technology (CEHRT), and to ensure that EHRs are meaningfully used to promote efficiencies and improved patient outcomes. To be eligible for the Medicaid EHR Incentive Program, providers must meet a minimum percentage threshold of Medicaid patients. The final rule included a number of changes related to how to calculate patient volume (PV). These changes to the PV calculation will allow for increased provider participation in the EHR incentive program through the updated definition of a Medicaid encounter and also through providing greater flexibility in the patient volume reporting period. During the comment period for the draft Stage 2 MU regulations, CMS received feedback indicating that there were points of confusion for providers under the initial patient volume requirements. Dentists, behavioral health providers and public health clinics, in particular, noted that some of the patient volume requirements seemed to impose unnecessary barriers to eligibility. In adopting the patient volume changes included in the Stage 2 regulations, CMS attempted to address these concerns while remaining within the parameters of the Health Information Technology for Economic and Clinical Health (HITECH) Act. Given the unique program structures and provider networks in each state, it is also CMS s intention to give state Medicaid agencies as much latitude as possible in how the patient volume requirements are applied. Based on initial interviews with several states, it seems that for some states the latitude afforded has been most helpful and they have been able to move forward with implementing the patient volume changes rather easily. In other cases, it has proved challenging to implement the necessary modifications in existing systems or attestation processes in a timely fashion. These differences may relate to the size of the state program, the way in which their automated systems are configured, the structure of their pre- and post-payment audit processes or the special processes they have set up to enable providers to prequalify. It is CMS s intent to work with individual states to address the challenges each is facing. It is important to retain the integrity of the systems and processes the states have put in place heretofore, but also to enable them to support the expansive inclusion of as many EPs and EHs as possible in moving forward with the 1 Centers for Medicare and Medicaid Services, Medicaid Program; Electronic Record Incentive Program; Meaningful Use Stage 2: Final Rule. Federal Register. September 4, 2012; Volume 77, No. 171: pages 53968-54162 Page 1 of 5
adoption of certified electronic health records systems and the meaningful use of the EHRs provided by these systems. Tips Related to Specific Patient Volume Provisions (45 CFR 495.306) 1. Practicing Predominantly Calculation Updated requirement: Allow EPs to use a 6-month period within the prior calendar year or preceding 12- month period from the date of attestation for the definition of practicing predominantly (more than 50 percent of encounters). States have some flexibility, but all approaches need CMS approval. (Effective 1/1/13 for affected EPs) This change was specifically intended to make it possible for providers who were only recently licensed, or who have recently committed to working in Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs), to qualify for the incentive payment. So, for example, previously a provider who received a medical license in September of calendar year 2011 would have had to wait until at least January 2013 to apply for an incentive payment. Under the change, the same provider could apply for the incentive payment during 2012 as long as the provider could attest to having more than 50 percent of his or her encounters at an FQHC or RHC for a full 6-month period during the preceding 12-month period before attesting. For many states this change will not pose any major problems, though it may require updates to the systems parameters used to qualify providers, to the claims extracts used to verify provider attestations, to pre-payment review processes, to provider education materials, to provider self- auditing materials and to post payment auditing materials. For other states, this change may also require updates to prequalification processes. States may also need to consider how they will handle overlapping time periods if a provider wants to attest for a calendar year one year and a 12-month period that overlaps the previous calendar year the following year. As states consider these issues, they are encouraged to contact their regional CMS representatives for guidance. 2. Medicaid Enrolled Encounters Updated requirement: Numerator to include service rendered on any one day to a Medicaid-enrolled individual, regardless of payment liability. Includes zero-pay claims and encounters with patients in Title XXI-funded Medicaid expansions, but not separate Children s Health Insurance Programs (CHIP). (Effective 10/1/12 for EHs, 1/1/13 for EPs) By moving away from the previous requirement that Medicaid must have a financial liability for the encounter in order to qualify, this change enables encounters to be used that are based on Medicaid enrollment. The updated requirement allows for encounters of a Medicaid member for a date of service to count towards the numerator as long as that member was enrolled in Medicaid or Title XXI-funded Medicaid expansions during their attested patient volume reporting period. This includes zero-pay encounters that may have been paid by Medicare (in the case of dual eligibles), or by another third party, to count in determining whether a provider meets the threshold for qualifying for a Medicaid EHR incentive payment. It also enables the provider to count in the numerator medical encounters provided to Page 2 of 5
Medicaid enrollees, for which no payment was received, as well as medical services provided that are not covered under the state s Medicaid program. Examples of encounters that may now be included are: claims denied due to service limitation audits claims denied due to non-covered service claims denied due to timely filing services rendered on Medicaid members that were not billed due to the provider s understanding of Medicaid billing rules This does not include claims denied due to the provider or member being ineligible for the date of service. (Note: There is no change in the requirements for the denominator. The denominator continues to include all patient encounters, including zero-pay encounters.) This change creates some of the biggest challenges for states because it is unlikely that their claims systems will capture data on all countable zero-pay encounters. States will need to identify or develop other means of verifying the additional encounters to which providers may attest. Some of this additional claims information may be readily available in states claims or encounter systems and can be used to augment their validation processes. For example, a claim for a service rendered may have been received and rejected/denied by the Medicaid program because of coverage policies, even though the client was enrolled in Medicaid. This is often particularly true for dental services. Rejected/denied claims can now be used in determining that a provider meets the patient volume threshold as long as the client was enrolled in Medicaid on the date the service was provided and the service provided was a billable medical service/office visit. 2 States should also consider utilizing reports from practice management systems to supplement their attestation data. Additionally, it may be possible for a provider to submit retrospective eligibility verifications (270/210 transactions) to the state s Medicaid system, or for the state to validate the same. States have indicated that they expect their Medicaid claims and encounter information will continue to be used as the primary basis for determining whether a provider meets the patient volume threshold. A riskbased approach to these changes is advisable. If the state s Medicaid claims and encounter data provide sufficient information to document that a provider is reaching their threshold, states have indicated they do not plan to seek additional documentation related to claims paid by Medicare or another third party. However, for providers who are at or near the threshold, the states will want to obtain additional documentation from those providers, from an all-payer claims database (APCD), where available, or from another resource. 2 an office visit is defined as any billable visit that includes: (1) Concurrent care or transfer of care visits; (2) consultant visits; or (3) prolonged physician service without direct, face-to-face patient contact (for example, telehealth). A consultant visit occurs when a provider is asked to render an expert opinion/service for a specific condition or problem by a referring provider. The visit does not have to be individually billable in instances where multiple visits occur under one global fee. (Federal Register, September 4, 2012, Volume 77, No. 171, page 53983) Page 3 of 5
3. CHIP Encounters Updated requirement: Provider patient volume includes CHIP encounters in numerator if part of Title XIX expansion or part of Title XXI expansion (still cannot include CHIP stand-alone Title XXI encounters). (Effective 10/1/12 for EHs, 1/1/13 for EPs) In many states, this change will help more providers qualify for the Medicaid EHR incentive program, because it expands the pool of encounters eligible to be counted in the numerator for patient volume calculations. It also should be helpful to states that have Title XXI expansion CHIP programs integrated into their Medicaid programs because it will no longer be necessary to remove the Title XXI CHIP expansion encounters from Medicaid claims for purposes of calculating the patient volume numerators. On the other hand, the updated requirement may create confusion in states that have stand-alone Title XXI CHIP programs because providers could mistakenly believe they may count these CHIP encounters in their numerator to meet their patient thresholds. States that have the stand-alone programs will need to update their provider education materials to make this distinction clear. It is probably the most challenging in states that operate both a Title XXI CHIP expansion and a CHIP stand-alone program. Provider education materials will have to be very clear. It could also be complicated in states in the midst of phasing out their stand-alone Title XIX CHIP program (like California). States in this situation are encouraged to contact their CMS regional staff to discuss options to reduce confusion for providers in areas of their state still in transition. 4. Panel Method Updated requirement: Change the period during which an encounter with a patient must take place from 12 months to 24 months to account for new clinical guidelines from the U.S. Preventive Services Task Force that allow greater spacing between some wellness visits. (Effective10/1/12 for EHs, 1/1/13 for EPs) At this time, only a handful of states allow the panel method for calculating patient volume. In checking with at least one of these states, staff indicate that this change did not require any significant effort. They are changing their existing systems parameters and queries and updating their provider education materials, audit instructions, etc. As states expand their managed care programs, however, they may consider allowing the panel method and will want to implement this change to help additional providers qualify for the incentive payment and align with the new clinical guidelines from the U.S. Preventive Services Task Force. 5. Ninety (90) Days in Preceding Twelve (12) Months Updated requirement: Allow providers to have their patient volume reporting period be any consecutive 90-day period within the prior calendar year or preceding 12-month period from the date of attestation. States have some flexibility, but all approaches need CMS approval. (Effective 10/1/12 for EHs, 1/1/13 for EPs) This change is mainly helpful to providers who are new participants in the Medicaid program, like those who are expanding their practice or were newly licensed later in a calendar year. It will allow them to use Page 4 of 5
a 90-day period in a more current 12-month period to meet the patient volume threshold rather than waiting until the end of a full calendar year. This update requires states to make changes to their attestation software. In some cases this may not be difficult to do. In others, systems updates may not be feasible in time for the effective date of January 1, 2013. In such cases, it may be necessary for states to arrange alternate processing options until the systems changes can be made. CMS is willing to be flexible in working with states to address this potential issue. In general, however, it is not anticipated that many providers will be ready to attest within the first 90 days of the new year, so states should be able to schedule their systems updates for this change in advance of any appreciable numbers of providers attempting to attest for a 90-day period in a recent 12- month period. Some states have also expressed concern that providers may want to attest to a 90-day period before the state has received claims or encounter data for that period. In these cases, the state may allow providers to attest and hold them in pre-payment status until the necessary encounter reporting or claims information has been received. "Many States have expressed to CMS their concern for holding an EP/EH in prepayment review for an extended amount of time due to the requirement to make a payment within 45 days. However, the 45 days requirement does not begin until the state Medicaid agency has approved the EP's/EH's EHR application for payment. This will allow states the time they need to complete their necessary prepayment review. " Patient Volume Changes Summary Chart The following chart summarizes impacts to key components of states EHR incentive programs resulting from the five major policy changes that occurred as part of the Stage 2 MU final regulations. Patient Volume Changes Effective January 1, 2013 Items States Should Consider Updating 1 Practicing Predominantly Calculation 2 Medicaid Enrolled Encounters 3 CHIP Encounters (where change is applicable) 4 Panel Methodology (where applicable) 5 90 days in preceding 12 months Patient Volume Systems Logic Claims Extracts Provider Education Prequalifying Processes Prepayment Review Processes Provider Selfauditing Postpayment Auditing SMHP IAPD Page 5 of 5