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

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Frequently Asked Questions

General

Q. 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.

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

Q. 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 patients over a 90-day period in the prior calendar year or in the 12 months before attestation. 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.

Q. What are zero-pay claims?

A: 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
Q. 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.

Q. 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 in the clinic agree to use the group rate for calculating Medicaid patient volume. If one does not agree to use the group calculation, then everyone has to use the individual patient volume calculation. If the entire clinic reaches the 30 percent paid Medicaid encounter threshold, all EPs in the clinic will have met the threshold. Only the EPs qualify for the incentive payment, even though other providers contributed to the Medicaid encounter volume.

Q. Per CMS FAQ #3017, my tribal clinic is considered an FQHC for the Medicaid EHR Incentive Program. Our EPs need to have 30 percent needy individual patient volume in order to qualify. I understand that needy individual encounters include encounters covered by Medicaid, the Children's Health Insurance Program (CHIP), a sliding fee scale or uncompensated care. My clinic receives IHS funding which only partially offsets the cost of these encounters that are not covered by Medicaid or CHIP, but my clinic does not impose costs on these individuals and does not have a sliding fee scale, so how do I count them?

A: Since your clinic receives IHS funding, the encounters are not truly uncompensated, but the encounters would be considered services furnished at no cost (even if your clinic does not have a sliding fee scale), and therefore can be counted toward needy individual patient volume for tribal clinic-based EPs applying for the Medicaid EHR Incentive Program.

Q. Per CMS FAQ # 3015, when EPs/Locum Tenens 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: Any EP demonstrating MU must have at least 50 percent of his/her patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHR technology capable of meeting all of the MU objectives. Therefore, states should collect information about meaningful users' practice locations in order to validate this requirement in an audit.

Patient Volume: EPs may choose one (or more) clinical sites of practice in order to calculate their patient volume. 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 adopting or 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. When making an individual patient volume calculation (i.e., not using the group/clinic proxy option), an EP may calculate across all practice sites, or just at the one site.

Q. 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 have a Medicaid encounter within a group practice can be included in the Medicaid group patient volume calculation.

Q. 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 in three potential ways to qualify for an incentive payment. For illustrative purposes, assume the EP in the below example joined the practice in 2013:

  • Next year (2014), after the EP establishes his/her own 90-day patient volume period as an EP from the prior calendar year (2013) or 12-month period prior to attestation, if this option is allowed by his/her state.
  • This year (2013), if he/she is part of a group using the group patient volume proxy and it is appropriate to include him/her (i.e., he/she see Medicaid patients*). It is not a requirement that he/she was in the group for the period that is the basis for the proxy. However, using the group patient volume proxy is distinct from whether an EP practices predominantly in a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC). To meet the "practice predominantly" criterion, an EP must use individualized data; there is no group proxy (see next bullet).
  • If the EP is working in an FQHC or RHC, next year (2014), after the EP practiced predominately in his/her the FQHC/RHC for at least 6 months. The EP could then use either individual or group proxy needy individual patient volume. FQHCs/RHCs using the group proxy must follow the regulations, including ensuring all EPs in the clinic use the proxy, and counting only encounters associated with the clinic (not an EP's outside encounters).

Each state has a method to determine whether an EP is considered hospital-based. Generally, the state uses data from the prior fiscal or calendar year to make this determination.

*Note that it is within the state’s discretion to require validation of an EP’s status as a Medicaid provider in the form of a paid encounter from the previous year. If the EP is new to practicing medicine (e.g., a recent graduate of an appropriate training program), he/she is not required to provide such information.

Attestation

Q. According to CMS FAQ # 5993, to qualify for payment under the Medicaid EHR Incentive Program for having adopted, implemented, or upgraded (AIU) to certified EHR technology, EPs working at an IHS clinic may be asked to submit to their state Medicaid agency an official letter containing information about the clinic's electronic health record from IHS. The information in this letter identifies the EHR vendor, the ONC Certified Heath IT Product List (CHPL) number of the EHR, as well as other information regarding the EHR product version and licensure. Does this letter meet states' documentation requirements for AIU?

A: Yes. This official letter is from the United States Department of Health and Human Services, and the IHS clinic generating this letter uses a certified EHR system created for the IHS. The state does not need to collect additional documentation for AIU (pre-payment or post-payment, or in the event of an audit) in instances where one of these letters is provided.

Q. Can attestation information submitted for the EHR Incentive Programs be updated, changed, cancelled, or withdrawn after successful submission in the EHR Registration and Attestation System?

A: Once a provider has submitted his/her attestation and has been either locked for payment or had an incentive payment issued, he/she will not have the ability to amend the information in the attestation system. It is the provider’s responsibility to maintain records that demonstrate the MU requirements have been met and to determine whether corrections to the attestation information would enable continued demonstration of MU.

If the provider is not able to demonstrate MU with the amended data, it is the provider’s responsibility to complete the Medicare EHR Incentive Program Return Payment/Withdrawal Form Exit Disclaimer: You Are Leaving www.ihs.gov and follow the instructions on the form explaining how to return their EHR incentive payment. Further instructions on the steps necessary to withdraw an attestation from the EHR Incentive Program can be found on the Medicare Incentive Payment Withdrawal Form.

Providers may access the online Meaningful Use Attestation Calculator tool Exit Disclaimer: You Are Leaving www.ihs.gov to enter their amended data and test whether they would continue to demonstrate MU.

EPs or EHs wishing to change or withdraw their attestation from a Medicaid EHR Incentive Program should contact their state directly to make this request.

Note that CMS does not require providers who relied on flawed software for their attestation information to submit amended attestation data.