Patient Volume Threshold (PVT) Massachusetts Medicaid EHR Incentive Program

Transcription

1 Patient Volume Threshold (PVT) Massachusetts Medicaid EHR Incentive Program April 25, 2017 Today s presenters: Thomas Bennett, MeHI Technical Assistance Team Elisabeth Renczkowski, Content Specialist

2 Disclaimer This presentation was current at the time it was presented, published or uploaded onto the web. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage attendees to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. 2 Massachusetts ehealth Institute

3 Agenda Purpose of This Webinar What is Medicaid Patient Volume Threshold (PVT)? Selecting Your Strategy PVT Prep Work Refining Your Strategy Methodology Individual vs. Group Proxy Defining and Selecting Your PVT Reporting Period Defining an Encounter Paid Claims vs. Enrollees Calculating Your Patient Volume Threshold Data Entry and Supporting Documentation List of Data Elements Required Reassessing Your Strategy Common Issues Questions 3

4 Purpose of This Webinar

5 Purpose of This Webinar We want to help you: save time by getting it right the first time ensure the accuracy of your PVT data At the end of this session, participants will understand: the purpose of Medicaid PVT options and strategies to optimize PVT while minimizing headaches how to clean up and organize PVT data to eliminate errors 5

6 What is Patient Volume Threshold (PVT)?

7 What is Medicaid Patient Volume Threshold (PVT)? Medicaid patient volume determines if a provider is eligible for the Medicaid EHR Incentive Program Ensures payments go only to providers who serve the target Medicaid population Eligible Professionals (EPs) must bill at least 30% of their encounters to Medicaid over a consecutive 90-day period Includes Fee-For-Service (FFS) and Managed Care Organization (MCO) see the Medicaid 1115 Waiver Population Grid for a complete list Board-certified pediatricians can meet a 20% threshold and receive a reduced incentive EPs who work at a Federally Qualified Health Center (FQHC) can include both needy individuals and Medicaid patients to meet the 30% threshold Patient volume eligibility must be demonstrated each year of participation; EPs must select a new reporting period every year PVT does not require use of the CEHRT; organizations may use their billing system to extract their volume 7

8 Selecting Your Strategy

9 Selecting Your Strategy Conduct a self-assessment to decide the most advantageous method for the Eligible Professional to meet the required eligibility threshold Learn about the options: The choices may seem confusing at first, but having a variety of options gives you a better chance of meeting the threshold Individual vs. Group Proxy Paid Claims vs. Enrollees PVT reporting period options Try the simplest way first Are there more than two EPs attesting for an incentive? Can the EP satisfy the 30% threshold using volume from one site? Can you extract the volume from your billing system? Pediatricians try for 30% first 9

10 PVT Prep Work More than just data entry Several things to consider before reporting in MAPIR: How is the data extracted and compiled? EHR, separate system, 3 rd party biller, etc. Assigning tasks Who is assigned to attest on behalf of the EP? - Acts as point of contact for MeHI staff - Completes MAPIR application - Uploads supporting documentation via MAPIR Who verifies the accuracy of the patient volume detail? - Retrieves raw data and exports to Excel - Organizes, formats, and cleans up data - Confirms accurate numerator and denominator - Calculates PVT 10

11 Refining Your Strategy

12 Methodology: Individual vs. Group Proxy To determine Medicaid Patient Volume eligibility, EPs may use either individual data or the Group Proxy Methodology. Individual data: each EP uses only his/her own patient encounters to establish Medicaid PVT Group Proxy Methodology: all providers in the practice (including those not eligible for the Medicaid EHR Incentive Program) aggregate their data to determine the group s Medicaid PVT A group is defined as two or more EPs practicing at the same site Please see our Group Proxy Guide for more information 12

13 Methodology: Individual vs. Group Proxy Once a method is selected, all attesting EPs must submit their applications using the same methodology An organization cannot have some EPs who use individual data and others who use Group Proxy Payment year and attestation phase (AIU vs. MU) do not impact Group Proxy providers at different phases of the program can still attest as a group Group Proxy Methodology usually involves less administrative burden and often allows more EPs to participate Dr. Green 25% Dr. Brown 35% Dr. Smith 35% Dr. Jones 35% Dr. Johnson 35% Group Total 33% Example: using individual data, Dr. Green would not qualify; aggregating the group s data allows all five EPs to participate 13

14 Defining Reporting Periods The PVT reporting period is any 90-day period from either the previous calendar year or the 12-month period leading up to attestation Simplest approach: choose one timeframe and stick to it Previous Calendar Year (CY) is always based on Program Year (PY), not the date of attestation For example, for PY 2016 applications, the previous CY is 2015, regardless of when you attest (even if you attest in 2017) Meaningful Use (MU) reporting period vs. PVT reporting period Both are 90 consecutive days* PVT reporting period is always from either the previous CY or the 12-month period leading up to attestation MU reporting period is within the Program Year 14 *For Program Year 2016 and 2017, MU reporting period is 90 days; for Program Year 2018, MU reporting period is scheduled to be 365 days

15 Selecting Your PVT Reporting Period Keep in mind the PVT reporting period selected for the previous Program Year Program Year Attestation Date Timeframe Selected PVT Reporting Period Options PVT Reporting Period Selected PY 2015 March 31, month period preceding attestation March 31, 2015 March 30, 2016 April 1, 2015 June 29, 2015 PY 2016 May 1, 2017 Previous CY (2015) January 1, 2015 March 31, 2015 ~~~~~~~~~~~~~~ June 30, 2015 December 31, 2015 July 1, 2015 September 28,

16 Selecting Your PVT Reporting Period, continued Organizations that used individual methodology for the previous Program Year and intend to use Group Proxy for the current Program Year should pay extra attention to reporting period(s) selected previously Program Year PVT Method Attestation Date Timeframe Selected PVT Reporting Period Options PVT Reporting Periods Selected PY 2015 Individual January 20, month period preceding attestation January 20, 2015 January 19, 2016 Dr. Jones: March 1, 2015 May 29, 2015 ~~~~~~~~~~~~~~ Dr. Smith: August 1, 2015 October 29, 2015 PY 2016 Group Proxy May 1, 2017 Previous CY (2015) None* *In this case, the organization would have to select a PVT reporting period from the 12-month period leading up to attestation (May 1, 2016 April 30, 2017) 16

17 Selecting Your PVT Reporting Period the No-Fly Zone 17 Month January 2015 February 2015 March 2015 April 2015 May 2015 June 2015 July 2015 August 2015 September 2015 October 2015 November 2015 December 2015 January 2016 February 2016 March 2016 April 2016 May 2016 June 2016 July 2016 August 2016 September 2016 October 2016 November 2016 December 2016 January 2017 February 2017 March 2017 April 2017 May 2017 Previous CY No-Fly Zone 12-month period preceding attestation

18 Defining an Encounter Paid Claims vs. Enrollees To determine patient volume eligibility, EPs may use either Medicaid paid claims or Medicaid enrollees. For EPs using paid claims, a patient encounter is defined as: One service, per patient, per day, where Medicaid or a Medicaid 1115 Waiver Population paid for all or part of the service rendered, or paid for all or part of the individual s premiums, co-payments, or cost-sharing For EPs using the enrollee approach, a patient encounter is defined as: One service rendered to a Medicaid or Medicaid 1115 Waiver enrolled patient, regardless of payment liability. This includes zero-pay encounters and denied claims (excluding denied claims due to the patient being ineligible on the date of service) Please see the Medicaid 1115 Waiver Population Grid for a complete list of payers that are considered Medicaid 18

19 Calculating Your Patient Volume Threshold

20 Calculating Your Medicaid Patient Volume Threshold Medicaid Patient Volume Threshold = Medicaid Patient Encounters (over any continuous 90-day period from the preceding calendar year or the 12 months preceding the provider s attestation) Total Patient Encounters (over the same 90-day period) Numerator: Medicaid Patient Encounters (FFS & MCO) Denominator: Total Patient Encounters (All payers) 20

21 Calculating Your Medicaid Patient Volume Threshold All encounters paid under the Children s Health Insurance Program (CHIP) must be removed from the numerator A percentage reduction (the CHIP factor) must be applied to the in-state numerator - The CHIP factor does not apply to out-of-state encounters The CHIP factor varies depending on the PVT reporting period chosen and is based on the last day of the reporting period Please see the CHIP Factor Grid on our website or contact us to determine the appropriate CHIP factor to apply to your numerator Example CHIP factor 3.20% Medicaid count (raw #) 300 CHIP applied 300 x.032 = = Medicaid count with CHIP 290 Please note: Federally Qualified Health Centers (FQHCs) using the FQHC method to determine patient volume do not need to apply the CHIP factor to their numerator 21

22 Data Entry and Supporting Documentation

23 Data Entry When preparing patient volume data for MAPIR, ensure you have obtained all the data elements shown below: Total In-State Medicaid Encounters 3,071 CHIP Reduction -3.20% -98 Reduced Total In-State Medicaid Encounters 2,973 Out-of-State Encounters 30 Reduced Total In-State plus Out-of-State Encounters 3,003 All Encounters from All Payers 9,706 % Medicaid 30.93% 27

24 Supporting Documentation Eligible Professionals are required to submit PVT supporting documentation only upon request Supporting documentation is requested when there is a variance of +/- 25% or greater between the PVT reported in the EP s MAPIR application and the claims information extracted from the MassHealth Data Warehouse All EPs should have their PVT supporting documentation available and retain all documentation for a minimum of 6 years post-attestation (in case of audit) PVT documentation must be provided in a searchable format (i.e. Excel) PVT supporting documentation must contain all required data elements 28

25 List of Data Elements Required

26 List of Data Elements Required Include the following tabs/sheets and data elements (column headers) within your Excel spreadsheet: Group Roster - Provider Name - Provider Type - NPI - Site - Group Name - Eligible to Participate in Medicaid EHR Incentive Program Y/N Payer Key - Abbreviations - Full names - Medicaid Y/N All Payers (Denominator) - See Medicaid list Medicaid (Numerator) - Organization Name - Payee NPI - Location/Street Address - Unique Patient ID 1 (MRN) - Unique Patient ID 2 (DOB) - Date of Service - Primary Payer - Total Amount Paid - Claim Status (Enrollee method only) - Denial Reason (Enrollee method only) Optional: - Rendering Provider Name - Rendering Provider NPI - Secondary Payer - Secondary Amount Paid - Tertiary Payer - Tertiary Amount Paid 30

27 Reassessing Your Strategy

28 Reassessing Your Strategy: Preparing for Future Years Keep in mind that a different PVT reporting period must be chosen for each Program Year No-Fly Zone Individual vs. Group Proxy issue Reassess the most advantageous strategy for your practice Maintain flexibility in your strategy your patient population may change over the course of the year Group vs. Individual patient population may further vary by provider Paid claims vs. Enrollees enrollee allows you to include zero-pay and denied claims (as long as the reason for denial wasn t ineligibility on the date of service) 32

29 Common Issues

30 Common Issues Difficulty extracting data from billing system Data may not be in a format that s conducive to determining Medicaid PVT Excluding legitimate MassHealth payers from numerator Issues identifying which payers are Medicaid (incomplete/inaccurate payer key) Confusion over what constitutes a group for Group Proxy Methodology Confusion around multiple sites or NPI/TIN combinations Failing to include non-eligible providers who billed Medicaid during the reporting period Three-month period vs. 90-day period Most three-month periods have more than 90 days; Feb-April actually has less 34

31 Common Issues, continued No-Fly Zone 90-day reporting period inadvertently falls outside 12-month period prior to attestation Failing to remove duplicates, zero-paid claims, typos Forgetting to apply the CHIP factor to the in-state numerator Difficulty understanding which numbers correspond to the MAPIR fields Supporting documentation must include 2 unique patient IDs (MRN and DOB) Do not include PHI (first name, last name, social security number, etc.) 35

32 Questions Questions? 36

33 Helpful Links MeHI MU Toolkit for Eligible Professionals Medicaid 1115 Waiver Population Grid Calculating Patient Volume CHIP Factor Grid Group Proxy Guide COMING SOON Updated PVT template spreadsheets Guide to Removing Duplicates 37

34 Contact Us Thomas Bennett Client Services Relationship Manager (508) , ext. 403 Brendan Gallagher Client Services Relationship Manager (508) , ext Al Wroblewski Client Services Relationship Manager (508) , ext. 603