Washington State recently announced a change to the Medicaid patient volume calculation related to the Medicaid EHR Incentive Program. Previously, Washington announced that it would provide all eligible professionals and hospitals with ProviderOne data on their respective Medicaid encounters for the time period chosen by the provider. Pursuant to the Medicaid EHR Incentive Program eligible professionals must show that they have at least a 30% Medicaid patient volume to qualify for the incentive payments (pediatricians can show 20% Medicaid patient volume), hospitals must show that they have a 10% Medicaid patient volume. The primary equation for calculating patient volume for eligible professionals is as follows (there is a second equation regarding managed care patients that is not discussed by this blog post, nor is the calculation for hospitals):
| Total Medicaid Patient Encounters | x 100 ≥ 30% | |||
| Total Patient Encounters | ||||
Washington, rather than providing the exact number of Medicaid encounters, is allowing the eligible professional to perform the calculation itself. Due to the eligible professional’s inability to differentiate between Medicaid, State Only payments, and CHIP, the state is providing a multiplier to calculate these ineligible encounters (note that rural health clinics and FQHCs may include CHIP patients in their patient volume calculations). Based on its analysis of ProviderOne historical paid fee for service claims and managed care encounter data for 2010 the average proportion of CHIP encounters equals 1% and State Only encounters equals 4%. Accordingly, the revised formula for eligible professionals will look as follows:
| Total Medicaid Patient Encounters * .95 | x 100 ≥ 30% | |||
| Total Patient Encounters | ||||
This new formula will reduce the percentage of Medicaid encounters and may make those eligible professionals who are on the cusp of meeting the 30% requirement ineligible. In response the state has offered an alternative, which allows any provider to request assistance from the state staff to analyze and report their actual data from ProviderOne. In addition, those eligible professionals who are audited and who use the multiplier will only be assesed as to whether the total Washington Medicaid encounters were accurately represented, and will not evaluate whether the CHIP and State Only encounters were correctly excluded.
Washington has since modified its State Medicaid Health Information Technology Plan to reflect this change. In addition, the state has offered an updated webinar on registration and calculation of patient volume, which can be accessed here.
Calculating patient volume can be complicated, especially when attempting to qualify for the incentive payments using the group practice calculation. For more information regarding the patient volume calculations or the Medicaid/Medicare EHR Incentive Program in general please contact Elana Zana.
