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19 OF THE MOST FREQUENT QUESTIONS AND ANSWERS ABOUT SC MEDICAID EHR INCENTIVE PROGRAM

Do I have to use the same Patient Volume method each year?

Answer: No!  If a provider or a practice used individual or needy volume in the past, they are NOT locked in to using that method for future program years. A decision to use group or individual proxy should be done prior to the program year deadline to see which method will help the most providers qualify. You are strongly encouraged to compare the two. 

SCROLL DOWN TO SEE ANSWERS TO THESE QUESTIONS

 

  1. If an EP practices at an outpatient location that has not implemented all the functionalities necessary for the EP to meet MU, is that location considered equipped with certified EHR technology? Must that location be included in the EP’s MU calculations? Does it matter if the location possesses ambulatory certified EHR technology covering the relevant MU objectives but does not implement them?
  2. When Providers work at more than one clinical site of practice, are they required to use data from all sites of practice to support their demonstration of MU and the minimum patient volume thresholds for the Medicaid EHR Incentive Program?
  3. Can EPs or EHs round their patient volume percentage when calculating patient volume in the Medicaid EHR incentive program?
  4. What is an unduplicated Medicaid “Encounter”?
  5. Can I use out¬-of¬-state Medicaid encounters when calculating patient volume?
  6. What types of encounters can an EP include in their Medicaid encounters?
  7. What are zero-pay claims and are these counted as Medicaid patient encounters?
  8. Does Medicaid need to pay any part of the claim for me to include a service to a Medicaid beneficiary?
  9. What is “Needy” Patient Volume and can I claim it?
  10. What time periods are available that I can select either my individual or group 90-day patient volume reporting period from?
  11. When can EPs use the Medicaid group patient volume calculation?
  12. What if my practice has a provider who didn’t begin working at the practice until after the date we selected to use for group patient volume?
  13. Are we able to include Medicaid encounters for our Medicare EPs in the Medicaid patient volume calculation when attesting as a group?
  14. How can an EP who is new to a practice meet the patient volume/practice predominantly criteria to be eligible for the Medicaid Electronic Health Records (EHR) Incentive Program?
  15. When a patient has multiple encounters on the same day with different providers, may all encounters be used for calculating patient volume?
  16. If a provider chooses to use a TIN’s group patient volume, do all the providers under the TIN have to participate in the Medicaid EHR Incentive Program?
  17. What is Patient Panel Method (for Managed Care)?
  18. For the Medicaid EHR Incentive Program, can a nonhospital based eligible professional (EP) include their in-patient encounters for purposes of calculating Medicaid patient volume even if the patient is included in the eligible hospital's patient volume for the same 90-day period?

 

 Q1. If an EP practices at an outpatient location that has not implemented all the functionalities necessary for the EP to meet MU, is that location considered equipped with certified EHR technology? Must that location be included in the EP’s MU calculations? Does it matter if the location possesses ambulatory certified EHR technology covering the relevant MU objectives but does not implement them?

A: No, this location is not equipped with certified EHR technology and should not be used to calculate whether the EP’s outpatient encounters meet the 50 percent threshold, nor would it be included in the calculations of the EP’s MU measures. This is true even if the location does possess ambulatory certified EHR technology covering the relevant MU objectives but does not implement the functionalities.

However, an EP can consider the location equipped with certified EHR technology only if he/she has access to certified EHR technology certified to the criteria applicable to an ambulatory setting, which fills the gaps between the technology implemented by the location and the certified EHR technology necessary to meet the relevant meaningful use objectives. If the EP chooses to equip the location with certified EHR technology with the applicable criteria, the EP must then include this location in all calculations, including both the 50 percent threshold calculation and the MU measures calculations.

Patient Volume

Q2. When Providers work at more than one clinical site of practice, are they required to use data from all sites of practice to support their demonstration of MU and the minimum patient volume thresholds for the Medicaid EHR Incentive Program?

A: CMS considers these two separate, but related, issues.

Meaningful Use Location Data: Any EP demonstrating MU must have at least 50 percent of his/her patient encounters during the EHR reporting period at one or more practice(s)/location(s) equipped with certified EHR technology capable of meeting all of the MU objectives.

Patient Volume Location Data: When making an individual patient volume calculation (i.e., not using the group TIN option), an EP may calculate across all practice sites, or just at the one site. EPs may choose one (or more) clinical sites of practice in order to calculate their patient volume (EPs should determine which method is best and must indicate which locations were included in their calculations in their attestations). This calculation does not need to be across all of an EP’s sites of practice. However, at least one of the locations where the EP is meaningfully using certified EHR technology should be included in the patient volume. In other words, if an EP practices in two locations, one with certified EHR technology and one without, the EP should include the patient volume at least at the site that includes the certified EHR technology.

Q3. Can EPs or EHs round their patient volume percentage when calculating patient volume in the Medicaid EHR incentive program?

A: To participate in the Medicaid EHR incentive program, EPs are required to demonstrate a patient volume of at least 30 percent of Medicaid or Needy patients (pediatricians only need to meet 20%) over a 90-day period in the prior calendar year, or in the 12 months before final submission of their attestation in the SLR. CMS allows rounding 29.5 percent and higher to 30 percent for purposes of determining patient volume. Similarly, pediatric patient volume may be rounded from 19.5 percent and higher to 20 percent. Finally, EHs are required to demonstrate a patient volume of at least 10 percent of Medicaid patients over a 90-day period in the prior fiscal year preceding the hospital's payment year or in the 12 months before attestation. An EH’s patient volume may be rounded from 9.5 percent and higher to 10 percent. Note: the SLR rounds up automatically.

Q4.  What is an unduplicated “Encounter”?

A:  Services rendered to an individual on any one day.

Q5.  Can I use out-of-state Medicaid/ Needy patient encounters when calculating patient volume?

A:  Yes, SCDHHS allows EPs to include out-of-state encounters when calculating patient volume. To calculate patient volume using this option, the EP would add their Medicaid or Needy (if eligible to claim Needy) out-of-state encounters to the numerator and include their in-state and out-of-state total patient encounters in the denominator.

Q6.  What types of encounters can an EP include in their Medicaid encounters?

A:  Acceptable Encounters for EPs Using Medicaid Patient Volume:

• Services rendered on any one day to a Medicaid enrolled individual, regardless of payment liability, including zero-pay, late, and some denied claims.

• Such services can be included in the provider’s Medicaid patient volume calculation if the services were provided to a beneficiary who is enrolled in Medicaid at the time the service was rendered, regardless of whether Medicaid paid anything on the bill.

Medicaid as the primary, secondary, and tertiary insurer can be counted toward the encounters. If Medicaid is secondary and the primary insurance paid more than the Medicaid allowable share (so Medicaid paid zero), then it could still be included as an encounter.

Q7. What are zero-pay claims and are these counted as Medicaid patient encounters?

A: Yes, as long as the service was provided to an individual enrolled in Medicaid, zero-pay claims may include:

• Claims denied because the Medicaid beneficiary has maxed out the service limit

• Claims denied because the services weren’t covered under the State’s Medicaid program

• Claims paid at $0 because another payer’s payment exceeded the Medicaid payment Claims denied because they were not submitted timely

Q8.  Does Medicaid need to pay any part of the claim for me to include a service to a Medicaid beneficiary?

A:  NO. This is a common misconception. It is relevant that a Medicaid beneficiary received service, but it is not relevant that Medicaid paid any part of the claim.

Q9.  What is “Needy” Patient Volume and can I claim it?

A:  “Needy” Patient Volume: is only available to providers that “practiced predominantly” in an Rural Health Center (RHC), Federally Qualified Health Center (FQHC), or Indian Health Service (IHS).

The following encounters qualify as  “Needy”:

• State Only funds or CHIP paid for all or part of the service; or individual’s premiums, copayments or cost-sharing in 2009; or

• Individuals receiving uncompensated care; or

• If services were furnished at no cost; or

• If services were paid for at reduced cost based on a sliding scale determined by an individual’s ability to pay.

To qualify to claim Needy patient volume the provider must have “Practiced predominantly” at a federally qualified health center (FQHC), rural health clinic (RHC) or Tribal Health Clinic. During a provider selected 6-month period while working at an FQHC, RHC, or Tribal Health Clinic, the provider must have had more than fifty percent (50%) of their total patient encounters with Needy individuals. This provider selected 6-month period must be from either the 12 months prior to submitting their attestation, or from within the calendar year prior to the program year (2017 if attesting to PY18).

Q10. What time periods are available that I can select either my individual or group 90-day patient volume reporting period from?

A:  SCDHHS opted to give providers more flexibility than other states by allowing providers to select their 90-day period from either the calendar year prior to the program year (the prior calendar year is 2017 for program year 2018); or within the 12 months prior to submission of the individual provider's attestation.

Sometimes, the SLR will give an error if providers select a period from the 12 months prior to attestation if all of the providers do not attest at the same time. If this happens, please contact us so we can fix it for you – you do not need to recalculate the volume again if this happens!

Q11. When can EPs use the Medicaid group patient volume calculation?

A: The Medicaid group patient volume calculation can be used when all of the providers under the same Tax Identification Number (TIN) agree to use group patient volume for reporting in their attestations for a given program year for the Medicaid Promoting Interoperability program. Note: this is only for the program year; past usage of group volume does not mean the TIN is locked into using this method for later years.

If a provider in the TIN does not agree to use the group calculation for their attestation to the Medicaid Promoting Interoperability Program, the practice may still claim the group volume and include that provider's patient volume from that practice. The individual provider can use patient volume from another location they work at that is not part of the TIN and attest to individual patient volume for example. 

Group volume allows individual providers to claim the qualifying threshold even if their individual Medicaid or Needy patient volume was lower than required. This method can allow more providers in your practice to become eligible.

All the providers working at the TIN during the TIN selected 90-day period combine all their Medicaid or Needy patient volume. This 90-day period can be from either the 12 months prior to submitting the attestations, or from the calendar year prior to the program year (that is 2017 if attesting to PY18). This group volume can be used for anyone attesting even if they were not working for the TIN during the time the volume was calculated (for example, a provider was hired after the 90-day reporting period. TINs should not recalculate their volumes in these situations).

Pediatricians can claim group volume to meet the 29.5% threshold to qualify for the higher incentive amounts (even if they do not meet the 19.5% or 29.5% individual volume). Group patient volume includes all providers, including providers who don’t participate in the EHR Incentive Program.

A provider needs to have a formal business relationship with the TIN group but does not necessarily need to use that group to bill claims. EPs may use a clinic or group practice’s patient volume as a proxy for their own under three conditions:

a.) The clinic or group practice’s patient volume is appropriate as a patient volume

methodology calculation for the EP (for example, if the EP does not or will not provide

services to Medicaid patients, then it is not appropriate for the provider to claim Medicaid

group volume to receive an incentive payment);

 

b.) There is an auditable data source to support the clinic’s patient volume

determination/ calculations; and

 

c.) So long as the EPs under the TIN decide to use one methodology in each program year (in

other words, clinics could not have some of the EPs attesting using their individual patient

volume for patients seen at the clinic, while others use the group's patient volume data). The

clinic or practice (TIN) must use the entire practice’s (TIN) patient volume and not limit it in

any way. EPs may attest to patient volume under the individual calculation or

the group/clinic proxy in any participation year. Furthermore, if the EP works in

both the clinic and outside the clinic (or with and outside a group practice),

then the clinic/practice level determination includes only those encounters

associated with the clinic/practice.

 

If a clinic or group practice chooses this methodology for the patient volume calculation, an EP in that clinic or group may choose to use the clinic volume as a proxy for their own; or, the EP may choose to attest to his or her own individual patient volume, so long as their individual volume calculation only includes the EP's encounters that are not included in the clinic's volume calculation. The clinic or group practice is also required to use the entire practice’s patient volume and not limit it in any way. SCDHHS has defined a group practice as a group of healthcare practitioners organized as one legal entity under one tax identification number (TIN). 

In order to provide examples of this, please refer to the following example for Clinics A and B and assume that these clinics are legally separate entities (i.e. they do not operate under the same Tax Identification Number (TIN)).

 

If Clinic A uses the clinic’s patient volume as a proxy for all EPs practicing in Clinic A,

this would not preclude the part-time EP from using the patient volume associated

with Clinic B and claiming the incentive for the work performed in Clinic B. In other

words, such an EP would not be required to use the patient volume of Clinic A simply

because Clinic A chose to invoke the option to use the proxy patient volume.

 

However, such EP’s Clinic A patient encounters are still counted in Clinic A’s overall

patient volume calculation. In addition, the EP could not use his or her patient

encounters from clinic A in calculating his or her individual patient volume.

 

The intent of the flexibility for the proxy volume (requiring all EPs in the group

practice or clinic to use the same methodology for the payment year) was to

ensure against EPs within the same clinic/group practice measuring patient volume

from that same clinic/group practice in different ways.

 

CLINIC A (with a fictional EP and provider type)

  • EP #1 (physician): individually had 40% Medicaid encounters (80/200 encounters)
  • EP# 2 (nurse practitioner): individually had 50% Medicaid encounters (50/100

encounters)

  • Practitioner at the clinic, but not an EP (registered nurse): individually had 75%

Medicaid encounters (150/200)

  • Practitioner at the clinic, but not an EP (pharmacist): individually had 80%

Medicaid encounters (80/100)

  • EP #3 (physician): individually had 10% Medicaid encounters (30/300)
  • EP #4 (dentist): individually had 5% Medicaid encounters (5/100)
  • EP #5 (dentist): individually had 10% Medicaid encounters (20/200)

 

In this scenario, there are 1200 encounters in the selected 90-day period for Clinic A.

There are 415 encounters attributable to Medicaid, which is 35% of the clinic’s

volume. This means that 5 of the 7 professionals would meet the Medicaid patient

volume criteria under the rules for the EHR Incentive Program. (Two of the

professionals are not eligible for the program on their own, but their clinical

encounters at Clinic A should be included.)

 

The purpose of these rules is to prevent duplication of encounters. For example, if

the two highest volume Medicaid EPs in this clinic (EPs #1 and #2) were to apply on

their own (they have enough Medicaid patients to do that), the clinic’s 35%

Medicaid patient volume is no longer an appropriate proxy for the low-volume

providers (e.g., EPs #4 and #5).

 

If EP #2 is practicing part-time at both Clinic A, and another clinic, Clinic B, and both

Clinics are using the clinic-level proxy option, each such clinic would use the

encounters associated with the respective clinics when developing a proxy value

for the entire clinic. EP #2 could then apply for an incentive using data from one

clinic or the other.

 

Similarly, if EP #4 is practicing both at Clinic A, and has her own practice, EP # 4

could choose to use the proxy-level Clinic A patient volume data, or the patient

volume associated with her individual practice. She could not, however, include

the Clinic A patient encounters in determining her individual practice’s Medicaid

patient volume. In addition, her Clinic A patient encounters would be included in

determining such clinic’s overall Medicaid patient volume.

 

Q12. What if my practice has a provider who didn’t begin working at the practice until after the date we selected to use for group patient volume?

A:  An EP whose date of hire falls after the 90-­day period selected for the group/ practice's patient volume calculation may claim the group/ practice's patient volume, as long as the newly hired EP sees, or will see, Medicaid patients (or needy patients if needy group patient volume is claimed). Groups/ practices should not recalculate their patient volume or use individual patient volume in these situations.

Q13. Are we able to include Medicaid encounters for our Medicare EPs in the Medicaid patient volume calculation when attesting as a group?

A: Yes. All providers who who practice at the location(s) used for the TIN's group patient volume should have their patient volumes included in the group's patient volume calculation, regardless of their eligibility for the Promoting Interoperability Program.

Q14. How can an EP who is new to a practice meet the patient volume/practice predominantly criteria to be eligible for the Medicaid Electronic Health Records (EHR) Incentive Program?

A: An EP could meet the patient volume/practice predominantly criteria by establishing that more than 50% of their patient encounters from the prior calendar year, or from within the 12 months prior to submitting their attestation in the SLR, were for Needy individuals (see user guide for definition and requirements). This requirement can only be met by providers who work/ worked at a Rural Health Center (RHC) or Federally Qualified Health Center (FQHC). 

If the practice/ organization is claiming group needy patient volume, it is not a requirement that the provider was working for the TIN group/ organization during the 90-day period used for the group patient volume (for example if the EP joined the practice in September 1, 2017 and the practice/ organizations group patient volume reporting period is from March 1, 2017 to May 30, 2017). The newly hired EP can claim the group patient volume and meet the practicing predominantly requirement in the 12 months prior to their attestation submission (for example from September to March 2018.

Q15. When a patient has multiple encounters on the same day with different providers, may all encounters be used for calculating patient volume?

A: Yes, multiple providers may include an encounter for the same individual seen by multiple providers on the same day. For example, it may be common for a physician assistant or a nurse practitioner to provide care for a patient, then for a physician also to see that patient. It is acceptable in circumstances like this to include the same encounter for multiple providers when it is within the scope of practice. When a patient has multiple encounters on the same day with different providers, all encounters may be used for calculating patient volume, assuming they meet the encounter definitions described above. Auditable documentation of patient encounters must be maintained and produced at the request of SCDHHS.

Q16. If a provider chooses to use a TIN’s group patient volume, do all the providers under the TIN have to participate in the Medicaid EHR Incentive Program?

A.  No. However, all the providers who were employed by the TIN organization at the time chosen for their group patient volume and regardless of eligibility or participation status in the Medicaid EHR Incentive Program, must be included in that TIN group’s patient volume. This volume can be across one TIN location or multiple locations but all providers at any included location must have their patient volumes included.  The same volume should be used for all participating providers for the program year they are attesting to. If you are not able to use the same patient volume due to an error in the SLR, please contact 803-898-2996 – this may be due to a technical issue and you need to speak with us asap.

If a provider joined the practice/ organization after the group patient volume reporting period, it is not necessary to re-calculate the group patient volume for another date range. The newly hired employees should claim the TIN's group patient volume even though they were not employed by the practice/ organization during those dates and their patient encounters were therefore not included.

 

Q17. What is Patient Panel Method (for Managed Care)?

A.  This is an alternate calculation that SCDHHS makes available. The requirements for the Panel Method to calculate patient volume, are to account for eligible professionals treating patients in a care management role (often managed care or a medical home), as well as any additional encounters outside of a care management arrangement. EPs who are primary care providers (PCP) that have Medicaid managed care or medical home patients (such as Patient Centered Medical Homes – “PCMHs”) assigned to them have the option to use a Managed Care Patient Panel method to calculate patient volume. The formula for determining eligible patient volume using patient panel assignments is:


 

 

[Total Medicaid patients assigned to the provider in any representative continuous 90-day

period in the preceding calendar year (or from within the 12 months prior to attestation submission) with at least one encounter in the calendar year

preceding the start of the 90-day period] PLUS +

[Unduplicated Medicaid encounters in that same 90-day period]

DIVIDED BY

[Total patients assigned to the provider (all payers) in the same 90-day with at least one

encounter in the calendar year preceding the start of the 90-day period PLUS + [All

unduplicated encounters in that same 90-day period.

 

Q18.  For the Medicaid EHR Incentive Program, can a nonhospital based eligible professional (EP) include their in-patient encounters for purposes of calculating Medicaid patient volume even if the patient is included in the eligible hospital's patient volume for the same 90-day period?

A.  Yes, an EP who sees patients in an in-patient setting, and is not hospital-based (defined as 90% or more of their covered professional Medicaid services were in a POS 21 or 23), can include the in-patient encounter in their Medicaid patient volume calculation. Both an eligible hospital and an EP can include an encounter from the same patient in their Medicaid patient volume calculations, respectively. This is because the services performed by the EP are distinct from those performed by the eligible hospital. Section 495.306 defines an encounter as a service rendered to an individual enrolled in a Medicaid program by either an EP or an eligible hospital.

 

An EP who sees patients in an in-patient setting bills Medicaid for the services personally rendered by the EP, while at same time the hospital bills Medicaid for the services rendered by the hospital, such as the bed and medications. Given that these are two distinct sets of services for the same patient, both the eligible hospital and the EP can count them as an encounter for Medicaid patient volume


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