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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

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Calculating Patient Volume

2011-2012 Reporting Period

Prior to 2013, the calculation used to determine Medicaid patient volume is based on the total number of patient encounters with an EP or EH (depending on who the calculation is for) paid in full or in part by Medicaid during a consecutive 90-day period in the reporting period. For EPs, encounters may be taken from any consecutive 90-day period during the qualification calendar year (January 1 - December 31). For EHs, encounters may be taken from any consecutive 90-day period during the qualification fiscal year (October 1 - September 30). Note that the 90 days may not span multiple calendar or fiscal years. The calculation itself is a simple ratio based on a numerator and denominator.

During the 2011-2012 reporting period, the numerator is defined as the number of patient encounters for an EP/EH during the same time-period where Medicaid paid for all or part of the service (co-pay, premium, or cost share). Thus, a qualifying encounter has two components: 1) the patient must be Medicaid eligible, and 2) Medicaid must have paid for some part of the encounter.

The denominator is defined as all patient encounters for the EP/EH during the same 90-day period.

Example: If an EH had 100 patient encounters and 10 were paid either in full or in part by Medicaid, the EH would have a patient volume of 10 percent.

Keep in mind that in order to participate in the EHR Medicaid Incentive Program, EPs must meet a 30 percent patient volume threshold (20 percent for pediatricians), and EHs must meet a 10 percent patient volume threshold.

Listed below are the formulas for calculating patient volume for 2011-12.

Individual EPs/EHs
Numerator - Medicaid paid claims
Denominator - All patient encounters

Group EPs/EHs
Numerator - Medicaid paid claims for the entire clinic
Denominator - All patient encounters for the entire clinic

*Needy Individual (Tribal/Urban/FQHC/RHC)
Numerator - Medicaid paid claims + Reduced fee and No fee claims
Denominator - All patient encounters

*In CY 2011 - 2012, the needy individual calculation is used for EPs who work predominately at a Tribal/Urban/FQHC/RHC clinic. An EP is considered to work predominantly at a Tribal/Urban/FQHC/RHC clinic when that clinic is the clinical location for more than 50 percent of all of the provider's total encounters for six months in the previous calendar year.

NOTE: Beginning in CY 2013, states will also have the option to allow providers to use a six-month period within the prior calendar year or the preceding 12-month period from the date of attestation for the definition of practicing predominantly.

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