CMS Posts Meaningful Use Stage 2 Specification Sheets

Looking for more detail on the Meaningful Use Stage 2 requirements?  CMS has conveniently created specification sheets for each Meaningful Use measure.  These sheets explain in detail each numerator and denominator eligible professionals and hospitals much achieve to be eligible for the EHR Incentive Payments.  The sheets also contain the certification and standards criteria issued from the Office of the National Coordinator.

For Eligible Professionals click here.

For Eligible Hospitals and Critical Access Hospitals click here.

For assistance with the EHR Incentive Programs and meaningful use in general please contact Elana Zana.

eRx Hardship Exemption Requests Extension

On November 1st CMS extended the time period for eligible professionals to request a hardship exemption under the e-Prescribing Incentive Program.  Those eligible professionals that have made at least 10 electronic prescriptions (eRx) between January 1, 2012-June 30, 2012 (for certain CPT codes) will not be subject to the Medicare penalties, and those that have prescribed 25 in 2012 will receive an incentive payment under the program (unless they are receiving the Medicare EHR Incentive Program incentives).  However, there are some eligible professionals that due to “hardships” cannot participate in this program, and CMS acknowledges should not be penalized.  Current hardship exemption categories include:

1.  The inability to e-prescribe due to local, State or Federal law or regulation.

2.  Providers that prescribe fewer than 100 prescriptions between January 1st and June 30, 2012.

3.  Providers practicing in a rural area without sufficient high speed internet access.

4.  Providers practicing in an area without sufficient available pharmacies for eRx.

To apply for a hardship exemption click here.  CMS has added the following two new hardship exemption request categories:

5.  Eligible professionals who achieve meaningful use during certain eRx timeframes. For the 2013 eRx payment adjustment, this will include any eligible professional who achieved meaningful use during January 1, 2011 through June 30, 2012 and has attested to this by January 31, 2013.

6.  Eligible professionals who demonstrate intent to participate in the EHR Incentive Program and adoption of Certified EHR Technology by registering for the EHR Incentive Program by January 31, 2013.  Please note: EHR Incentive Program participants must provide their entire EHR Certification Number  in the CMS EHR Certification ID field during registration to receive this hardship.

For these last two hardship exemption categories, eligible professionals do not have to apply through the Communications Support Page.  But instead must register and attest for the EHR Incentive Program by January 1, 2013.

If you have questions regarding the eRx program please contact Elana Zana.

Comparison of Stage 1 vs Stage 2 Meaningful Use

Sifting through the hundreds of pages of new rules can be overwhelming.  Luckily, CMS has provided comparison charts to help navigate the meaningful use changes coming our way with Stage 2.  Along with the new rules, CMS clarified that the earliest Stage 2 meaningful use is effective is fiscal year 2014 for hospitals and calendar year 2014 for eligible professionals (more on 2014 to come in future posts).

Click on the links below to see the comparison charts:

Stage 2 Meaningful Use – Eligible Professionals: 17 core objectives, 3 of 6 menu objectives, 9 of 64 clinical quality measures.

Stage 2 Meaningful Use – Hospitals & CAHs: 16 core objectives, 3 of 6 menu objectives, 16 of 29 clinical quality measures.

For more information about meaningful use and the EHR Incentive Programs please contact Elana Zana.

CMS Issues 3 FAQs on Stage 2 Rules and the Medicaid EHR Incentive Program

CMS has responded to several questions following the issuance of its Stage 2 Meaningful Use Final Rule.  Along with publishing new meaningful use guidelines, the Final Rule adds new provisions regarding the calculation of patient volume for Medicaid providers.  CMS has recently published these new FAQs, some of which take effect immediately, while others will start in 2013, giving the states some time to update their guidance.  These new rules will affect all eligible professionals, regardless of their stage in participation in meaningful use.  To see additional FAQs click here.

Medicaid changes to patient volume calculations 

Q: The EHR Incentive Programs Stage 1 Rule stated that, in order for a Medicaid encounter to count towards the patient volume of an eligible provider, Medicaid had to either pay for all or part of the service, or pay all or part of the premium, deductible or coinsurance for that encounter.  The Stage 2 Rule now states that the Medicaid encounter can be counted towards patient volume if the patient is enrolled in the state’s Medicaid program (either through the state’s fee-for-service programs or the state’s Medicaid managed care programs) at the time of service without the requirement of Medicaid payment liability. How will this change affect patient volume calculations for Medicaid eligible providers?  

A: Importantly, this change affecting the Medicaid patient volume calculation is applicable to all eligible providers, regardless of the stage of the Medicaid EHR Incentive Program they are participating in. Billable services provided by an eligible provider to a patient enrolled in Medicaid would count toward meeting the minimum Medicaid patient volume thresholds.  Examples of Medicaid encounters under this expanded definition that could be newly eligible might include: behavioral health services, HIV/AIDS treatment, or other services that might not be billed to Medicaid/managed care for privacy reasons, but where the provider has a mechanism to verify eligibility.  Also, services to a Medicaid-enrolled patient that might not have been reimbursed by Medicaid (or a Medicaid managed care organization) may now be included in the Medicaid patient volume calculation (e.g., oral health services, immunization, vaccination and women’s health services, telemedicine/telehealth, etc.).

Providers who are not currently enrolled with their state Medicaid agency who might be newly eligible for the incentive payments due to these changes should note that they are not necessarily required to fully enroll with Medicaid in order to receive the payment.

In some instances, it may now be appropriate to include services denied by Medicaid in calculating patient volume.  It will be appropriate to review denial reasons.  If Medicaid denied the service for timely filing or because another payer’s payment exceeded the potential Medicaid payment, it would be appropriate to include that encounter in the calculation.  If Medicaid denied payment for the service because the beneficiary has exceeded service limits established by the Medicaid program, it would be appropriate to include that encounter in the calculation.  If Medicaid denied the service because the patient was ineligible for Medicaid at the time of service, it would not be appropriate to include that encounter in the calculation.

Further guidance regarding this change will be distributed to the states as appropriate.

CHIP patients eligible to be included in Medicaid patient volume totals
Q: The Stage 2 Rule describes changes to how a state considers CHIP patients in the Medicaid patient volume total when determining provider eligibility. Patients in which kinds of CHIP programs are now appropriate to be considered in the Medicaid patient volume total?  

A: States that have offered CHIP as part of a Medicaid expansion under Title 19 or Title 21 can include those patients in their provider’s Medicaid patient volume calculation as there is cost liability to the Medicaid program in either case (under the Stage 1 Rule, only CHIP programs created under a Medicaid expansion via Title 19 were eligible). Patients in standalone CHIP programs established under Title 21 are not to be considered part of the patient volume total (in Stage 1 or Stage 2). This change to the patient volume calculation is applicable to all eligible providers, regardless of the stage of the Medicaid EHR Incentive Program they are participating in.

Changes to the base year of the Medicaid EHR Incentive Program for hospital incentive payment calculation 
Q: Are there any changes to the base year for the Medicaid EHR Incentive Program hospital incentive payment calculation?

A: Yes. Previously Medicaid eligible hospitals calculated the base year using a 12 month period ending in the Federal fiscal year before the hospital’s fiscal year that serves as the first payment year.  In an effort to encourage timely participation in the program, §495.310(g)(1)(i)(B) of the Stage 2 Rule was amended to allow hospitals to use the most recent continuous 12 month period for which data are available prior to the payment year. This change went into effect upon publication of the Stage 2 Rule.  Only hospitals that begin participation in the program after the publication date of the Stage 2 Rule (i.e., program years 2013 and later) will be affected by this change.  Hospitals that began participation in the program prior to the Stage 2 Rule will not have to adjust previous calculations.


Stage 2 Meaningful Use Final Rules Announced

After much delay and anticipation, the Stage 2 Meaningful Use Final Rules were announced late last week.  Though the primary focus of the new rules were to update (and increase) the meaningful use objectives and measures for the Medicare and Medicaid EHR Incentive Program, significant additional components regarding the EHR Incentive Program were also included.  To read the 672 pages of the Final Rule click here.  CMS has also posted a fact sheet which provides a good high level summary of some of the main topics of the Final Rule.  In addition to the Meaningful Use final rules, the Office of the National Coordinator has released its new standards governing certified EHR technology and a fact sheet.  The National eHealth Collaborative hosted a helpful webinar with an overview of these new rules, which can be accessed here.

Stay tuned for further information and analysis of these new rules, including an update regarding 2014, batch reporting for groups, commencement of payment adjustments, Medicaid patient volume calculations, new meaningful use measures, and more.

For immediate assistance regarding these new rules or for information regarding Stage 1 Meaningful Use and the EHR Incentive Program generally please contact Elana Zana.

ONC Issues Guide on HIPAA Privacy and Security and Meaningful Use

ONC has recently released a new “Guide to Privacy and Security of Health Information” which incorporates tips on complying with HIPAA Privacy and Security as well as meeting related meaningful use measures.  The guide is designed for clinical providers and focuses on the following:

  • Privacy & Security and Meaningful Use
  • Security Risk Analysis and Management Tips
  • Working with EHR and Health IT Vendors
  • A Privacy & Security 10-Step Plan
  • Health IT Privacy and Security Resources

Specifically, with regard to Meaningful Use, the guide describes Meaningful Use measures 12 and 15:

#12. Provide patients with an electronic copy of their health information (including diag­nostics test results, problem
list, medication lists, medica­tion allergies) upon request.  To learn more about this measure click here.

#15. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.  To learn more about this measure click here.

If you have questions regarding HIPAA Privacy and Security or Meaningful Use please contact Elana Zana.


Washington State EHR Incentive Program Seminars

The Washington State Health Care Authority has announced a traveling seminar on calculating and registering for the Medicaid EHR Incentive Program.  The seminar is aimed at group registration and defining the group proxy methodology to calculate patient volume.

The seminars are as follows:

May 1: Wenatchee
May 3: Spokane
May 8: Yakima
May 16: Seattle
May 17: Mt. Vernon
May 22: Silverdale
May 24: Olympia

To register click here (the link will take you to the Seattle registration, scroll down on that page for other registration links).


CMS Releases Proposed Rule On Meaningful Use Stage 2

CMS announced today its proposed rule (NPRM) on Stage 2 of the EHR Incentive Program Meaningful Use requirements.  These requirements apply to both eligible professionals and hospitals participating in the Medicare and Medicaid EHR Incentive Program.  As previously announced, and proposed within this NPRM, the onset of the Stage 2 meaningful use requirements will not begin until 2014.

The Stage 2 requirements include greater applicability to specialists, changes to the clinical quality measures, and modifications to the core and menu measures.  CMS has issued a fact sheet that briefly summarizes the Stage 2 requirements.

The NPRM will be published in the Federal Register on March 7, 2012.

For questions regarding the Stage 2 proposed requirements or for assistance related to the Medicare or Medicaid EHR Incentive Program please contact Elana Zana.

EHR Contracting Tip: Attestation for AIU

Now that most states have their Medicaid EHR Incentive Program in full swing we have gotten a glimpse of what they are requiring for attesting to “adopt, implement and upgrade” aka “AIU”.  As described in the CMS rules themselves, practices need to show that they have some skin in the game and have actually invested in an EHR product.  Many states are asking that an EP (or group practice) upload the actual EHR software contract (or a redacted version).  Some states (such as California) are requesting a signed vendor statement in lieu of the full contract.  

If you are a practice in the process of negotiating an EHR contract, you may want to consider including a provision in the contract specific to the AIU attestation requirements of the state your practice is in.  For example, requiring in the contract itself that the software vendor execute any documents required by the state to attest to AIU or that the vendor provide a letter acknowledging the practice’s EHR license (if such a letter is acceptable in your state). Similar provisions are recommended in situations where the practice is involved with a Stark donation arrangement or other type of third party contract. 

Setting expectations up front and creating a contractual obligation will help ensure that the software vendor or other third party contractor does not stand in the way of your practice receiving EHR incentive dollars.

For assistance in drafting and negotiating EHR software contracts or the Medicaid EHR Incentive Program in general please contact Elana Zana or Dave Schoolcraft.            

ACO Final Rule – Drastically Reduces Quality Measure Requirements

The Accountable Care Organization (“ACO”) final rules show that comments to CMS really do make a difference.  The public outcry against the 65 quality measures proposed in the spring led to CMS’ 50% cut of the number quality measures.  Along with the large cut, CMS explained its plan for allowing ACOs to meet the measure requirements by reporting on the measures in the first year and receiving “pay for performance” in the following years based on the weighted scores received in each quality measure.

Quality Measures

The revised list of quality measures are broken out into 33 different measures (predominately with NQF measure numbers) with four umbrella categories and five subcategories as follows:

  1. Patient/Caregiver Experience (7 measures)
  2. Care Coordination/Patient Safety (6 measures, includes the EHR Incentive Program)
  3. Preventative Health (8 measures)
  4. At Risk Population (12 measures)
    1. Diabetes (6 measures)
    2. Hypertension (1 measure)
    3. Ischemic vascular disease (2 measures)
    4. Heart failure (1 measure)
    5. Coronary Artery Disease (2 measures)

The tables provided in the final rule at pages 67889-90 are particularly helpful in visually identifying the measures, the method of data submission and whether the particular measure is pay for reporting or pay for performance.  The measures will be submitted to CMS through either surveys (for patient/caregiver experience measures), claims, the EHR Incentive Program, or the Group Practice Reporting Option (“GPRO”) Web Interface.  The surveys will be conducted using the Consumer Assessment of Healthcare Providers and System (“CAHPS”) surveys for 2012 and 2013, in future years, ACOs will have to select a CMS approved vendor to administer the surveys.

EHR Incentive Program

One of the significant changes to the quality measures was the expansion of the EHR incentive program related measure.  The quality measure no longer requires that 50% of the primary care providers to achieve meaningful use in order for the ACO to participate.  The EHR quality measure now recognizes those participating in the Medicaid EHR Incentive Program do not have to meet meaningful use requirements in their first year of participation.  As such, the new measure now includes primary care providers that successfully qualify for the EHR Incentive Program under either Medicare or Medicaid.  In addition, CMS cut previously proposed measures that were redundant with the EHR Incentive Program such as the measure concerning clinical decision support and electronic prescribing.

CMS still emphasizes the importance of the usage of the EHR technology by giving the EHR quality measure a higher weight.  Eligible professionals participating in ACOs are still eligible to separately participate in the EHR Incentive Programs or the e-prescribing incentive program.

Pay for Reporting vs. Pay for Performance

In the first year of participation, all of the quality measures may be satisfied by merely reporting on the quality measures.  For pay for reporting, ACOs will earn the maximum sharing rate for complete and accurate reporting of 100% of the required data, and no quality threshold must be met.  In the second year, 25 of the quality measures will be pay for performance, and eight will continue to be pay for reporting.  In the third year, all but one quality measure will be on a pay for performance basis.

In the pay for performance years, each domain will be given equal weight of 25% in the calculation of the ACOs overall quality performance score.  Each of the individual measures will be equally weighted within the domains, except for the EHR Incentive Program quality measure which is double weighted.  ACOs must minimally attain 30% (or be in the national 30th percentile) for that quality measure.  Subregulatory guidance will indicate the quality performance rates an ACO needs to achieve in order to earn the maximum quality points in a domain.

Recognizing that meeting all 33 measures in a given year may be difficult, CMS is requiring that ACOs achieve the quality performance standards on 70% of the measures in each domain.  Failure to achieve the 70% standard will result in a corrective action plan and re-evaluation in the final year.  However, if an ACO scores a zero for an entire measure, it will not be able to share in the savings generated.  Due to the double weight of the EHR measure, failure to meet the EHR measure in the Care Coordination domain would cause the ACO to miss the 70% cut-off.

Reporting Calendar & PQRS

ACOs are expected to report on the quality measures on a calendar year basis, beginning with the reporting period starting January 1, 2012 through December 31, 2012.  Even though a “performance year” in the regulations may begin in April or July of 2012 and end in December 2013, the quality performance for the first performance year will be based on reporting of the measures from January 1, 2013 through December 31, 2013.  Eligible professionals participating in an ACO that start the agreement in April or July of 2012 will also qualify for the 2012 PQRS incentive under the Shared Savings program by reporting the ACO GPRO measures for the full 2012 Physician Quality Reporting System (“PQRS”) calendar year reporting period.

Note that ACO participant entities that want to qualify for PQRS must participate as group practices and not separately participate or earn a PQRS incentive outside of the Shared Savings Program.  Individual ACO providers may not seek to qualify for the individual PQRS incentive under the traditional PQRS plans.  CMS also relaxed its requirements regarding the PQRS incentives.  If an ACO fails to meet the Shared Savings Program quality performance measures and therefore is not eligible for shared savings, the participating entities may still be eligible to receive the PQRS incentive under the Shared Savings Program.   

More Updates Coming

ACO participants should keep an eye out for subregulatory guidance which will detail the annual measure specifications.  CMS plans on releasing specifications in December and in the first quarter of 2012.

For more information regarding the ACO quality measures or ACOs in general, please contact Elana Zana.