EPs - Steps to MU Incentive Payments

I've been reading article after article about Meaningful Use and the difference between the Medicaid and Medicare incentive programs.  Much of this data is scattered and not always easy to understand.  The purpose of this blog is to highlight the important details of the Medicare and Medicaid incentive programs available to Eligible Professionals through the HITECH Act and American Recovery and Reinvestment Act of 2009.   The process to receive incentive payments can be broken down into seven distinct steps.  These steps are examined below:

Step 1. Determining Eligibility: The first step for an EP is to determine which program, Medicare or Medicaid, they are eligible for, if any.  The program requirements and definitions are very different among the two programs.  For example, to qualify for the Medicaid program, an EP must have 30% or more Medicaid patients (20% - 30% for Pediatricians).  CMS's Eligibility Wizard can be found here.  This will run through a number of questions to determine in which program an EP is eligible to participate.

Also very different among the two programs are the incentive payment amounts and the schedule of payments. 

• Medicaid program:
• Higher total incentive payment = $63,750
• No late start penalty
• Payments are distributed over six years 
• Prior to 2015, if an EP fails to meet meaningful use measures, they can skip that year and not lose a layer of payments
• Can take advantage of A/I/U
• Medicaid incentive payments are made by the States
• NOTE: This program is administered individually by each State - find out information about your State's program here.
• Medicare program:
• Lower total incentive payment = $44,000
• Medicare payments are based on 75% of the total Medicare allowed charges submitted no later than two months after the end of the calendar year
• Late start penalty by 2013
• Payments are distributed over five years
• If an EP fails to meet meaningful use measures, they lose the incentive payment for that year.
• Extra 10% available for EPs practicing predominantly in a Health Professional Shortage Area (HPSA) 

Step 2. Register: EPs that would like to participate in either Incentive program should register with CMS.  CMS encourages possible participants in the incentive programs to register as early as possible.  EPs can register for the program without a certified EHR system but cannot attest.  As part of the registration process, the EP must designate who will receive the incentive payments.

EPs will need the following information during registration:

• National Provider Identifier (NPI)
• National Plan and Provider Enumeration System (NPPES) User ID and Password
• Payee Tax Identification Number (only if you choose to reassign your benefits)
• Payee National Provider Identifier ( only if you choose to reassign your benefits)
• Third Party Registration - A user registering on behalf of an EP will need an Identity Access Management System (I&A) User ID and Password.  To obtain an account, visit the I&A Security Check.

When you have all of your required information, visit the CMS registration website.  CMS has provided a Medicaid Program User Guide and Medicare Program User Guide to assist individuals through registration.

In order to participate in the Medicare Incentive program, EPs must also be enrolled in the Provider Enrollment, Chain and Ownership System (PECOS).   EPs can access PECOS by using the User ID and password assigned to them when they applied to the NPPES for their National Provider Identifier (NPI).

Step 3: Select an Incentive Program: EPs are eligible to participate in either the Medicare or Medicaid incentive programs but they cannot participate in both program simultaneously like Eligible Hospitals.  As mentioned earlier, there are many differences between the programs eligibility requirements as well as the incentive payments so EPs should thoroughly examine their patient population to decide which program would be more beneficial.  Incentives for EPs are based on the individual EPs numbers, not the numbers of the entire practice collectively.  Also, all the doctors in a practice do not need to participate in the same incentive program.  

If an EP is participating in the Medicaid program, the requirement for Year 1 is only to adopt, implement, and/or upgrade (A/I/U) to certified EHR technology. Therefore, there is no reporting period for the Year 1.

It is important to note that EPs can switch between the Medicare and Medicaid programs one time after the initial incentive payment has been made before 2015 .

Step 4: Obtaining Certified EHR Software: In order to eligible to apply for incentive programs, EPs must be using certified EHR software.  ONC has created a certification process to certify vendor software and allow EPs to self-certify homegrown systems. EPs can obtain certified EHR software in one of three ways: purchasing a Complete EHR, purchasing Modular EHRs to meet all HITECH requirements, or self-certifying their own software.

A complete EHR has been tested and certified by an Authorized Testing and Certification Body (ACTB) and meets all of the government’s requirements as a whole. This means that if an EP implements a complete EHR, they can register for an Incentive Program and begin attesting to Meaningful Use criteria once they have met meaningful use measures for a consecutive 90-day reporting period.

A modular EHR allows an EP to combine certified modules from different systems in order to meet the government requirements for a certified EHR. For modular certification, the ONC Certification Numbers for each of the certified products must be collected and submitted to ONC as a ‘package’ solution. ONC reviews the package solution and if it meets all requirements for a certified system, they issue a new certification number which is used to attest Meaningful Use (MU).

EPs can also self-certify a homegrown system or an outdated version of a vendor system.  Modular products also allow an EP to buy some certified modules in addition to self-certifying their system to meet the requirements on the remaining modules. 

ONC lists all products that are certified as Complete or Modular on the Certified Health IT Product List (CHPL).

Step 5: Meeting Meaningful Use Measures: To be a 'meaningful user' of certified technology means to use the EHR in a meaningful manner to improve the quality of health care.  Once an EP has certified technology in place, they should review the incentive program Meaningful Use Measures to ensure that all necessary work flow procedures are in place to capture all required data.   

EPs must meet 15 core meaningful use measures, 5 of 10 menu meaningful use measures, and 6 clinical quality measures (3 core or alternate core, and 3 of 38 from menu set).  All objectives have a specific measure; some measures are percentage based and some are a yes/no attestation.  Some measures have exclusions because they are not relevant to a certain provider's practice or patient population.  An example of an exclusion is an EP who sees no patients that are 13 years or older will be excluded from the measure to 'record smoking status for patients 13 years old or older.'

Step 6: Attest to Meaningful Use Measures:   An EP must complete a continuous 90-day reporting period within the calendar year of the incentive program in order to attest. So, if an EP wishes to begin their incentive program in 2011, they must complete their 90-day reporting period before December 31, 2011. Once an EP has completed their 90-day reporting period, they are ready to attest to meeting the meaningful use measures.  An EP has sixty days after the close of a calendar year to submit their attestation data to CMS. 

Visit the Attestation page on the CMS website for more information.  CMS has also provided an Attestation User Guide, Attestation Worksheets and a Meaningful Use Attestation Calculator.

After reporting on all meaningful use measures in the CMS registration and attestation system, data will immediately be submitted and the user will be notified if the submission was successful.  Upon notification that the submission is complete and successful, the EP is qualified to receive their incentive payment.

Payments for the Medicare incentive program can be expected approximately 4 - 8 weeks after attestation.  EPs should note that if they have not met the $24,000 threshold for allowed charges at the time of attestation, CMS will hold the incentive payment until the threshold is met.  Incentive payments are based on the charges from the entire calendar year, not just charges from the 90-day reporting period.  If an EP has still not met the threshold by the end of the calendar year, the payment is held 60 days after the end of the calendar year to allow all pending claims to be processed.

SUCCESS!....but don't forget Step 7......

Step 7: Prepare for potential audits: Any EP that attests to meaningful use to receive incentive payments for either the Medicare or Medicaid program is subject to auditing from CMS. In order to prepare yourself for a potential audit, retain all supporting paper and electronic documentation used during attestation.  EPs should also keep documentation supporting their Clinical Quality Measures (CQM).  This documentation should be saved six years after attestation.  If, during an audit, an EP is found to be ineligible for the incentive payment, the payment will be recouped by CMS.  CMS plans to create an appeals process and will post more information on this process to their website soon.

The Direct Project - Gluing EHR's Together

Most of us believe that the push towards Electronic Health Records (EHR’s) is a good thing and a necessary step along the road toward making each person’s EHR available for any healthcare provider who might need to treat that patient, whether the patient is in Los Angeles or Prairieville, LA. This goal of universal EHR availability is called the Nationwide Health Information Network (NHIN). Providers are certainly making progress towards the NHIN, prodded along by the governments “carrot and stick” approach under the HITECH Act (Meaningful Use) Stage 1 and the availability of better technology and more tech-savvy healthcare providers.  

 

Another step toward NHIN is enabling EHR’s to talk to one another. Until recently, communication between EHR’s from different vendors was a bit like people located in different countries and speaking different languages, not fluent in each other’s language, trying to converse by telephone. There is a standard called HL7 but it was designed to exchange transactional data, not an entire health record. HITECH Stage 1 provided for the use of either the CCD or CCR a standard, which is, effectively, a universal language. One other piece seems to have been neglected until this year, however – and was omitted from HITECH Stage 1 – a secure standard for exchanging CCD/CCR clinical data. Think of this piece as the phone line in the international conversation.

 

Although that was a major oversight, it is being quickly (relative to how quickly things happen in healthcare IT) addressed through something called the “Direct Project” (http://wiki.directproject.org/). According to a February 2, 2011 News Release from HHS.gov, the goal of the Direct Project is an:

 

“easy-to-use, internet-based tool that can replace mail and fax transmissions of patient data with secure and efficient electronic health information exchange”

 

Towards this end, there have been committees, meetings, etc. and some standards have emerged.

 

The Direct Project has widespread support. According to Dr. Doug Fridsma, on his March 21 “HealthIT Buzz” posting, “support for the Direct Project represents approximately 90% of market share covered by the participating health IT vendors”.

 

In the next post, we’ll address the technological underpinnings of the Direct Project.

 

Definitions: 

• CCD/CCR –The ASTM Continuity of Care Record (CCR) and the Continuity of Care Document (CCD) HL7 standard. The HL7 CCD standard actually resulted from a collaborative effort between HL7 and ASTM to harmonize the data format between ASTM’s Continuity of Care Record (CCR) standard and HL7’s Clinical Document Architecture (CDA) standard.
• HITECH – In February of 2009, the American Reinvestment and Recovery Act (ARRA) allocated $19 billion in funding for hospitals and clinics that make “meaningful use” of certified Electronic Medical Record (EMR) systems. The Health Information Technology for Economic and Clinical Health (HITECH) Act lists criteria for eligible hospitals and vendor software

What is ONC?

ONC is the Office of the National Coordinator for Health Information Technology. The Office of the National Coordinator operates within the Office of the Secretary for the U.S. Department of Health and Human Services (HHS). ONC’s primary focus is the coordination and implementation of health information technology and electronic exchange of health information.  

 

According to ONC’s website, their mission includes the following:

 

• Promoting development of a nationwide Health IT infrastructure that allows for electronic use and exchange of information that:
• Ensures secure and protected patient health information
• Improves health care quality
• Reduces health care costs
• Informs medical decisions at the time/place of care
• Includes meaningful public input in infrastructure development
• Improves coordination of care and information among hospitals, labs, physicians, etc.
• Improves public health activities and facilitates early identification/rapid response to public health emergencies
• Facilitates health and clinical research
• Promotes early detection, prevention, and management of chronic diseases
• Promotes a more effective marketplace
• Improves efforts to reduce health disparities
• Providing leadership in the development, recognition, and implementation of standards and the certification of Health IT products;
• Health IT policy coordination;
• Strategic planning for Health IT adoption and health information exchange; and
• Establishing governance for the Nationwide Health Information Network.

The position of the National Coordinator was established in 2004 by George Bush’s administration and legislatively mandated by the HITECH Act. Farzad Mostashari, a physician and public health expert, currently holds the position of National Coordinator. Mostashari took the position in July 2009.

 

ONC has played a large role in the Medicare and Medicaid Electronic Health Record Incentive Programs established under the HITECH Act. ONC wrote the Final Rule documentation, a staged approach to adopting capabilities, standards and specifications required for achieving meaningful use. To date, only documentation on meeting the measures for Stage 1 of meaningful use have been released to the public. Furthermore, ONC was tasked with establishing a program for the testing and certification of health information technology as being in compliance with certification criteria to meet defined meaningful use requirements. ONC wrote testing requirements, test cases and test tools with NIST and established ONC-Authorized Testing and Certification Bodies (ATCB’s) to perform the testing and certification of EHR systems. ONC has selected six organizations to serve as ATCB’s. ONC also maintains the ONC Certified HIT Product List (CHPL), a list of certified Inpatient and Ambulatory EHR systems. The CHPL can be viewed here.

What is a CAH?

A CAH is a critical access hospital.  

A CAH is a hospital that is certified to receive cost-based reimbursement from Medicare. The reimbursement that CAHs receive is intended to improve their financial performance in order to reduce hospital closures. Each hospital must review its own unique situation to determine if becoming a CAH would be beneficial. CAHs are certified under a different set of Medicare Conditions of Participation which are more flexible than the acute care hospital Conditions of Participation.

The following is a list of criteria that a hospital must meet in order to be considered a CAH: 

• Located in a state that has a State Flex Program
• Designated by the State as a CAH
• Located in a rural area
• Provide 24-hour emergency care services
• Provide no more than 25 inpatient beds; a CAH can also operate a rehabilitation or psychiatric unit with up to 10 beds
• Have an average annual length of stay of 96 hours or less
• Located more than 35 miles from the nearest hospital or CAH (or more than 15 miles in areas with mountainous terrain or only secondary roads)
• Participate in Medicare

In addition to receiving cost-based reimbursement from Medicare, some other advantages of becoming a CAH are having access to Flex Program grant funds, flexible staffing and services, and having the CAH network with acute care hospitals for support.