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Focus on the Final Rule Please submit all questions via the WebEx Q&A function. Additional questions may be submitted to: meaningfuluse@healthland.com Focus on the Final Rule EHR Certification & Meaningful Use Final Rule Legal Restrictions & Guidance Daniel Gottlieb

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focus on the final rule2

Please submit all questions via the WebEx Q&A function.

Additional questions may be submitted to: meaningfuluse@healthland.com

Focus on the Final Rule

EHR Certification & Meaningful Use

daniel gottlieb

Final Rule

Legal Restrictions & Guidance

Daniel Gottlieb

Partner, McDermott Will & Emery LLP

agenda
Agenda
  • Who is an eligible hospital (EHs)?
    • Medicare Incentives
    • Medicaid Incentives
  • Who is an eligible professional (EP)?
    • Medicare Incentives
    • Medicaid Incentives
  • Exclusion of inapplicable meaningful use (MU) objectives
agenda cont d
Agenda (cont’d)
  • Changes to Medicare and Medicaid incentive calculations
  • Registration and attestation process and timelines
  • Certification of EHR Technology
  • Stark Law EHR Donation Exception
    • Independent physicians on Medical Staff
    • Hospital-Owned Clinics
medicare eligible hospitals
Medicare Eligible Hospitals
  • Medicare EHs: a hospital located in one of the 50 states or D.C. that participates in the Medicare Inpatient Prospective Payment System (IPPS) and Maryland acute care hospitals
  • CAHs are also eligible for incentives
  • Multi-campus hospital with a single provider number is a single hospital
medicare eligible hospitals7
Medicare Eligible Hospitals
  • Excludes IPPS-excluded hospitals and hospital units such as:
    • Psych hospital - Rehab hospital
    • Children's hospital - LTCHs
  • Surgical and other specialty hospitals participating in IPPS are eligible for Medicare incentives
medicare eligible professionals
Medicare Eligible Professionals
  • Medicare EPs include doctors of: medicine or osteopathy; dental surgery or dental medicine; podiatric medicine; optometry or chiropractry
  • Hospital-based physicians who provide 90% or more of their covered services in a hospital inpatient or ER setting are ineligible
medicaid eligible hospitals
Medicaid Eligible Hospitals
  • EHs include “acute care hospitals” and children’s hospitals
  • An “acute care hospital” is a hospital where the ALOS is 25 days or fewer and a CCN that has the last four digits in the series 0001-0879 (short-term general hospitals and 11 U.S. cancer hospitals) and now under the final rule also 1300-1399 (CAHs)
medicaid eligible hospitals10
Medicaid Eligible Hospitals
  • Acute care hospital must have at least 10 percent Medicaid Patient Volume based on patient encounters
  • Like other Medicaid EHs, CAHs may receive both Medicare and Medicaid EHR incentive payments
  • If an EH meets Medicare MU requirements, it will be deemed to meet Medicaid MU requirements
medicaid eligible professionals
Medicaid Eligible Professionals
  • Medicaid EPs are the following professionals (other than hospital-based professionals):
    • Physicians and dentists
    • nurse practitioners
    • certified nurse-midwives
    • physician assistants practicing in FQHCs or RHCs that are led by a physician assistant
medicaid eligible professionals12
Medicaid Eligible Professionals
  • A PA leads an FQHC or RHC under any of the following circumstances:
    • when a PA is the primary provider in a clinic (for example, when there is a part-time physician and full-time PA
    • when a PA is a clinical or medical director at a clinical site of practice
    • PA is an owner of the RHC
medicaid eligible professionals13
Medicaid Eligible Professionals
  • Medicaid EP must satisfy one of three Patient Volume thresholds:
    • Have ≥ 30% Patient Volume attributable to Medicaid recipients
    • Have ≥ 20% Patient Volume attributable to Medicaid recipients and be a pediatrician
    • practice predominantly in a FQHC or RHC and have ≥ 30% Patient Volume attributable to Needy Individuals
medicaid eligible professionals14
Medicaid Eligible Professionals
  • Needy Individuals are persons who:
    • received medical assistance from Medicaid or the Children’s Health Insurance Program
    • were furnished uncompensated care or
    • were furnished services either at no cost or reduced cost based on a sliding scale determined by individuals’ ability to pay
inapplicable mu objectives
Inapplicable MU Objectives
  • Some MU objectives do not apply to every provider so provider would not have any eligible patients or actions for the measure denominator
  • In these cases, provider may exclude (i.e., not meet) the measure
  • Exclusions do not count against the deferred measures in the menu set
inapplicable mu measures
Inapplicable MU Measures
  • For example, an EH or CAH that did not have request for electronic copy of discharge instructions may exclude core MU Objective #12 and only comply with 13 of 14 objectives
  • An EH or CAH that is excluded from a menu set objective must only meet 4 rather than 5 of 10 objectives
medicaid incentive calculation
Medicaid Incentive Calculation
  • CMS clarified that employer’s or FQHC’s purchase of EHR for use by employed EPs is not a payment
  • CMS did not address whether payments from other sources could include EHR donation to independent physician practice under Stark EHR donation exception
registration
Registration
  • To participate in incentive programs, eligible provider must register on incentive program website at http://www.cms.gov/EHrIncentivePrograms/
  • Medicaid programs will interface with program registration website
  • Registration begins in January 2011
registration19
Registration
  • Registration requirements include:
    • Name, National Provider Identifier, business address and phone number
    • Taxpayer identification number
    • Hospital’s CCN
    • EPs must select Medicare or Medicaid
    • Medicaid providers must select one state
attestation for medicare ffs
Attestation for Medicare FFS
  • Eligible providers demonstrate MU to CMS through attestation in 2011 and attestation and electronic reporting of clinical quality information in 2012
  • Providers may submit attestations as early as April 2011 to CMS
  • Payment begins as early as May 2011 following attestation
attestation for medicare ffs21
Attestation for Medicare FFS
  • CMS will provide a web-based tool for attestation
  • CMS has not released attestation tool
  • CMS is developing an audit strategy to verify attestations and prevent fraud and abuse
  • Providers should develop compliance and document retention procedures
attestation to states
Attestation to States
  • States must identify attestation and/or electronic reporting mechanism in their State Medicaid HIT Plans, subject to CMS approval
  • States must develop audit and verification procedures
attestation and reporting
Attestation and Reporting
  • FY 2011: EH or CAH must attest that during the EHR reporting period, it:
    • Used certified EHR technology and specify technology
    • Satisfied required MU objectives and measures
    • Must specify the EHR reporting period and provide the result of each applicable measure for inpatients and ER patients during the reporting period
attestation and reporting24
Attestation and Reporting
  • FY 2012 and after: EH or CAH must attest that during the EHR reporting period, it:
    • Used certified EHR technology and specify EHR
    • Satisfied required MU objectives and measures except clinical quality reporting
    • Must specify the EHR reporting period and provide the result of each applicable measure
  • EH or CAH must electronically report clinical quality measures through a portal (or, if feasible HIE or registry)
ep s attestation and reporting
EP’s Attestation and Reporting
  • For CY 2011: EP must attest that during the EHR reporting period, EP:
    • Used certified EHR technology and specify technology
    • Satisfied required MU objectives and measures
    • Must specify the EHR reporting period and provide the result of each applicable measure
ep s attestation and reporting26
EP’s Attestation and Reporting
  • For CY 2012 and after: EP must attest that during the EHR reporting period, EP:
    • Used certified EHR technology and specify EHR
    • Satisfied required MU objectives and measures except clinical quality reporting
    • Must specify the EHR reporting period and provide the result of each applicable measure
  • EP must electronically report clinical quality measures through a portal (or, if feasible HIE or registry)
medicare eh payment process
Medicare EH Payment Process
  • Single payment contractor pays an EH or CAH a preliminary, estimated EHR incentive payment based on most recently filed 12-month cost report as early as May 2011 following successful MU attestation
  • Final payment determined at time of settling cost report that begins on or after start of payment year
medicare ep payment process
Medicare EP Payment Process
  • Single payment contractor makes annual incentive payment to an EP when EP demonstrates MU and earns the maximum annual incentive payment
  • Payments begin as early as May 2011 following successful demonstration of MU on attestation
ehr certification
EHR Certification
  • ONC published the temporary EHR certification program final rule on 6/24/2010, which establishes :
    • selection process for testing and certification bodies (ONC-ATCBs)
    • parameters under which the ONC-ATCBs will test and certify that EHR meets the EHR certification requirements
  • ONC will make a Certified EHR list available this Fall
review of medicare s timeline
Review of Medicare’s Timeline
  • Fall 2011: Certified EHR technology on EHR incentive program website
  • January 2011: Registration begins on incentive program website
  • April 2011: Attestation of MU begins through web tool
  • May 2011: Medicare incentive payments begin
stark ehr donation exception
Stark EHR Donation Exception
  • Stark Law provides an exception for subsidies for EHR items and services
  • Exception applies to subsidies for EHRs used in private physician practice offices
  • Hospital may purchase inpatient or ambulatory EHR for use in hospital facilities to serve hospital patients without meeting exception
other resources
Other Resources
  • Comprehensive McDermott White Paper regarding final EHR certification and meaningful use regulations to be issued shortly
  • Healthcare Informatics article regarding Stark EHR donation exception
daniel f gottlieb

Daniel F. Gottlieb

Partner, McDermott Will & Emery LLP

dgottlieb@mwe.com

312-984-6471

ralph llewellyn

Final Rule

Accounting Requirements &

Incentive Guidelines

Ralph Llewellyn

Partner, EideBailly

reimbursement topics
Reimbursement Topics
  • Medicare
    • Medicare Share
    • PPS Hospitals
    • Critical Access Hospitals
    • Eligible Professionals
  • Medicaid
    • Same
medicare share
Medicare Share
  • Based on inpatient volume
    • Numerator
      • Medicare days + Medicare Advantage patient days
        • IP, specialty care
          • Psych and Rehab included in proposed rule, but eliminated in final rule
        • Excludes Swing Bed
medicare share37
Medicare Share
  • Based on inpatient volume
    • Denominator
      • Total inpatient days TIMES
        • Hospital charges less charity care DIVIDED BY hospital charges
          • Worksheet C Part I Line 200 Column 8
medicare share38
Medicare Share
  • Based on inpatient volume
    • Denominator
      • Total inpatient days TIMES
        • Hospital charges less charity care DIVIDED BY hospital charges
          • Worksheet C Part I Line 200 Column 8
      • Charity Care
        • As identified on Worksheet S-10 of the Medicare cost report for PPS Hospitals
        • Not reported on Medicare cost report for CAH’s in the past
pps hospitals
PPS Hospitals
  • Initial Amount
    • Base payment for each PPS hospital = $2,000,000
      • Adjusted for discharges 1,150 to 23,000
    • $200 additional per discharge in this range
    • Times your Medicare Share
pps hospitals40
PPS Hospitals
  • Payment Process
    • Hospital data last filed 12 month cost report
    • Settled based on the first 12 month cost reporting period that begins after the start of the payment year
pps hospitals41
PPS Hospitals
  • Transition Factor (FFY 2011 – 2013)
    • Year 1 = 1
    • Year 2 = ¾
    • Year 3 = ½
    • Year 4 = ¼
    • Subsequent Years = 0
pps hospitals42
PPS Hospitals
  • Transition Factor (FFY 2014 – 2015)
    • If the facility’s first year of eligibility is after FFY 2013, the transition factor is the same as a facility with a first payment in FFY 2013
    • If the first payment year is after FFY 2015, the transition factor
critical access hospitals
Critical Access Hospitals
  • Allowed to expense their costs associated with the purchase of certified EHR technology in a single year
    • Versus depreciating these costs on the cost report
    • Current year and prior year purchases (undepreciated value)
    • Includes only purchases for hospital specific EHR technology
critical access hospitals45
Critical Access Hospitals
  • Continued
    • Reimbursement based on Medicare Share + 20 percentage points (not to exceed 100%)
    • Lump sum prompt payment subject to reconciliation
      • Initial based on last filed 12 month cost report
      • Final based on final cost report
critical access hospitals46
Critical Access Hospitals
  • Continued
    • Payments up to 4 consecutive years
      • Stages
      • Replacement equipment
critical access hospitals47
Critical Access Hospitals
  • Allowable expense
    • Reasonable cost – “computers and associated hardware and software necessary to administer EHR technology”
      • Vendor implementation costs not included in this incentive calculation
      • Communicate with MAC/FI
critical access hospitals48
Critical Access Hospitals
  • Allowable expense
    • Incentive payment in lieu of depreciation AND interest
      • “Be smart about your interest”
    • Cost not reportable on future cost reports
    • Subject to reconciliation
eligible providers
Eligible Providers
  • Incentive
    • 75% of secretary’s estimate of allowed charges for covered services furnished by eligible professional during relevant payment year
      • Paid claims no later than 2 months after relevant year
    • Up to 5 years
    • No incentive after 2016
eligible providers51
Eligible Providers
  • HPSA incentive
    • 10% increase in incentive
      • Provides services predominately in HPSA
      • Defined as greater than 50%
      • January 1 – December 31 frequency
      • If HPSA by December 31 of prior year
        • No impact if HPSA lost during current year
        • No impact if HPSA obtained during current year
eligible providers53
Eligible Providers
  • Single consolidated payment
    • Ascertain professional has demonstrated meaningful use
    • Reaches maximum payment limit
    • If maximum payment limit is not reached payment is processed 2 months after relevant payment year
  • Multiple employers/contractual arrangements
    • Assign incentive to 1 employer or entity
medicaid
Medicaid
  • PPS Hospitals and Critical Access Hospitals can participate in Medicare and Medicaid
  • Eligible providers must elect, with option for one change
medicaid hospitals
Medicaid - Hospitals
  • PPS and CAHs reimbursed under same methodology as Medicare PPS
    • Medicaid Share versus Medicare Share
    • Payment made over 3 – 6 years
medicaid eligible providers
Medicaid – Eligible Providers
  • Incentive payment to EP equals Net Average Allowable Costs for EHR
  • NAAC is Average Allowable Costs (capped at $25K in yr 1 and $10K in yrs 2-6) net of cash payments attributable to EHR technology or support services from sources other than state and local governments, subject to 15% EP responsibility
ralph llewellyn59

Ralph Llewellyn

Partner, Eide Bailly LLP

RLlewellyn@eidebailly.com

701-239-8594

robert forrest

Healthland’s Role in

Getting you to MU

Robert Forrest

Healthland ARRA Task Force

meeting meaningful use
Meeting Meaningful Use

Eligible hospitals must

  • Implement certified EHR technology
  • Use it in a “meaningful manner”

Healthland will

  • Develop EHR technology that meets meaningful use requirements
  • Obtain Certification from an ONC-ATCB
slide62

For more information

Email: meaningfuluse@healthland.com

Phone: 800.323.6987 xt.3211

Web: www.healthland.com/stimulus