Electronic Health Records Incentives and Meaningful Use Penalties- A New Round of Questions Answered

Recently, we have received several inquiries from health centers regarding Electronic Health Record (EHR) Incentives and “meaningful use” (MU) requirements and penalties as prescribed in the HITECH Act. As most health centers will recall, due to the more generous benefits available under the Medicaid incentive program, virtually all eligible health center providers opted to participate in the Medicaid versus Medicare EHR incentive program. Health center organizations were not eligible as entities due to the HITECH Act’s focus on “eligible professionals” not health center organizations. Many readers will also recall that there were no downward payment adjustments under the Medicaid incentive program for failing to demonstrate meaningful use, only the potential loss of incentives themselves. However, as the date for Medicare payment adjustments approaches (January 1, 2015) some health centers are wondering whether they should be worried. Here are some Frequently Asked Questions (FAQs) and the answers.
Q: Are health center providers who participated in the Medicaid EHR incentive payment program subject to downward adjustments to their health center’s base Medicaid payment rate?
A: No. The Medicaid EHR Incentive program does not have payment penalties for failure to demonstrate meaningful use though participating providers do have to demonstrate meaningful use to continue receiving incentive payments.
Q: Are health centers’ Medicare FQHC claims subject to downward adjustment due to failure to demonstrate meaningful use?
A: No. The HITECH Act and its accompanying regulations indicate that for providers who fail to meet meaningful use standards there is a payment adjustment to the “covered professional services” billed by the eligible professional under the Medicare physician fee schedule. Health center Medicare FQHC payments are not made under the fee schedule.
Q: Could health center providers be facing payment adjustments January 1, 2015 to Medicare services billed outside of the FQHC rate under the Medicare Part B fee schedule if they fail to demonstrate meaningful use?
Q: What are the payment adjustments for providers who fail to demonstrate meaningful use?
The non-FQHC Medicare fee schedule claims of eligible health professionals at health centers could be adjusted down by 1% per year capping out at 5%.
Q: Which professionals are subject to these adjustments?
The fee schedule claims of all eligible professionals who fail to demonstrate meaningful use are subject to adjustments January 1, 2015. Eligible professionals are essentially all physicians as defined in the Medicare stature, such as: a doctor of medicine or osteopathy, a doctor of dental surgery or medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor. Eligible professionals who demonstrated meaningful use in Medicare or Medicaid in 2013 are not subject to 2015 reductions but will need to demonstrate meaningful use again in 2014 to avoid 2016 payment adjustments.


Recent Medicaid Developments from the States

Since the elections, there has been a flurry of Medicaid expansion activity in the states that we wanted to make sure you were aware of.

NEW HAMPSHIRE: New Hampshire submitted an 1115 waiver to transition their traditional Medicaid expansion into premium assistance in the marketplace for 2015. Read New Hampshire’s proposal here.

INDIANA: Indiana received a one year extension of their current waiver, which means their pending 1115 waiver to expand Medicaid is still being negotiated.

ARIZONA: Arizona has submitted an amendment to their Medicaid expansion 1115 waiver which would impose premiums and increase co-pays. Read Arizona’s 1115 amendment here.

In addition a handful of states have recently released Medicaid expansion proposals. A great deal of debate in these states is expected before waiver applications land at the Centers for Medicare and Medicaid Services (CMS). However, if successful, the poorest populations in another five states could gain Medicaid coverage.

FLORIDA: Florida is considering a premium assistance approach named “A Healthy Florida Works” which includes premiums, healthy behavior incentives, and job-seeking/training requirements.

UTAH: Utah is debating a premium assistance model which would include employer sponsored coverage or a plan on the marketplace. The Utah approach includes co-pays, job-search/training, and healthy behavior incentives. Read more about details about the Healthy Utah plan here.

WYOMING: Governor Mead voiced support for the Wyoming Health Department’s version of Medicaid expansion called the Strategy for Health, Access, Responsibility, and Employment (SHARE) program which would utilize current providers for a benchmark benefit package and also include premiums and co-pays, healthy behavior incentives, and employment assistance. Access Wyoming’s plan here, and read more about it in the Washington Posts’ article, “Wyoming’s Republican Governor Will Push to Expand Medicaid,”, Georgetown University Health Policy Institute’s blog, “Wyoming Medicaid Waiver Could Pass Muster with CMS”, or Families USA’s report, “Top 9 Occupations of Working but Uninsured in Wyoming Who Would Benefit from Expanding Health Coverage” and corresponding infographic.

MONTANA: Montana, like Wyoming, is considering an approach to utilize current providers for a benchmark benefit package. More details will be released soon.

TENNESSEE: Tennessee announced their plan to seek an 1115 waiver to expand Medicaid. Details include the choice of premium assistance or employer-sponsored coverage, premiums, co-pays, and healthy behavior incentives.

Additionally, Families USA has updated two Medicaid expansion resources—including an updated map showing where states stand on Medicaid expansion and an updated page on state Medicaid expansion waivers.

HRSA Issues “Frequently Asked Questions” to Clarify Certain Aspects of the Sliding Fee Discount Program Policy

In keeping with recent trends pertaining to the issuance of new policies and guidance, the Health Resources and Services Administration (HRSA) recently issued Frequently Asked Questions (FAQs) to clarify certain aspects of PIN 2014-02: Sliding Fee Discount and Related Billing and Collections Program Requirements. While some of the FAQs appear to reiterate the requirements set forth in the PIN, the document includes several important clarifications regarding, among other things, the extent of board approval, eligibility assessment, the definitions of income and family size, and discounts on supplies. In particular, the following provide additional clarification above and beyond what was included in PIN 2014-02.

  • While governing boards are required to approve the Sliding Fee Discount Program (SFDP) policies that establish the foundation for the SFDP, they are not required to approve the supporting and related operating procedures.
  • For purposes of Uniform Data System reporting, health centers are required to assess income and family size for all patients regardless of whether an individual patient would qualify for the SFDP and/or insurance status.
  • When determining eligibility for the SFDP, health centers:
    • Are not allowed to include assets in the income calculation, either as an additional threshold or as part of a “net worth” calculation.
    • Can include as part of “family size” persons who are not living with the patient but who are largely dependent on the patient’s income.
  • Health centers have flexibility to establish charges for service-related supplies and materials (such as eyeglasses, dentures, etc.) that are greater than a full slide, provided that the charge is less than the “locally prevailing charge” for the item and this discount facilitates patient access.

Additionally, the FAQ document clarifies that the SFDP requirements apply equally to Health Care for the Homeless (Section 330(h)) programs; thus, HCH programs must establish fee and sliding fee discount schedules similar to those established for other populations. Nevertheless, health centers retain flexibility in establishing the related operating procedures to minimize barriers to care.

HRSA noted that new FAQs will be added as necessary. Accordingly, Primary Care Associations and health centers are encouraged to continue submitting questions and requests for clarification to HRSA. For additional information on PIN 2014-02, please see the Policy Shop blog from October 7, 2014, entitled “HRSA Issues Much Anticipated Sliding Fee Discount Program Policy.”

HRSA Issues Revised Site Visit Guide to Include Requirements from New Policies

HRSA Issues Revised Site Visit Guide to Include Requirements from New Policies

On November 24, 2014, the Health Resources and Services Administration (HRSA) issued a revised Health Center Program Site Visit Guide (the Guide), effective December 1, 2014. The updated Guide incorporates revisions and clarifications that were initially included in several HRSA policies and guidance documents issued during calendar year 2014, including Policy Information Notice (PIN) 2014-01: Health Center Program Governance and PIN 2014-02: Sliding Fee Discount and Related Billing and Collections Program Requirements. Specifically, the Guide incorporates the following revisions:

  • Requirement #2 (Required and Additional Services) was revised to clarify that the compliance assessment of required and additional services should focus solely on whether (i) the health center is providing all required services; and (ii) for all in-scope services provided via written contract or formal, written referral agreement (Columns II or III of Form 5A – Services), whether required or additional, there is an appropriate agreement in place. The accuracy of a health center’s scope of project with respect to Form 5A should be documented under Requirement #16 (Scope of Project), while findings regarding whether services are available under an appropriately structured sliding fee discount program regardless of the mode of delivery (consistent with PIN 2014-02) should be documented under Requirement #7 (Sliding Fee Discounts).
  • Requirement #7 (Sliding Fee Discounts) was updated to include questions to align and assess compliance with PIN 2014-02.
  • Requirement #12 (Financial Management and Control Policies) was updated to delete all references to “Financial Recovery Plans” since HRSA no longer requires or utilizes them for health center monitoring. For additional information on this change, please see the Policy Shop blog from September 9, 2014, entitled “HRSA’s September 3, 2014 Weekly Digest Includes Clarifications Regarding HRSA’s Role in Monitoring. [Susan – please add link to the Policy Shop blog from September 9]
  • Requirement #13 (Billing and Collections) was updated to include questions to assess compliance and align with PIN 2014-02.
  • Requirement #17 (Board Authority) was revised to clarify that all organizations must now meet monthly, regardless of prior waiver status, consistent with PIN 2014-01 (which eliminated the monthly meeting requirement for special population only health centers). Because the January 2014 version of the Guide was issued around the same time as PIN 2014-01, it allowed health centers with previously approved monthly meeting waivers to demonstrate that they had “begun or completed a plan to transition the board to holding monthly meetings,” rather than verifying full compliance with the new requirement. At this point in time, HRSA expects that all centers are (or should be) compliant with the meeting requirement and thus, this qualification was eliminated from the new version of the Guide.

As noted above, HRSA has indicated that the updated Guide is effective as of December 1, 2014; accordingly, review teams conducting Operational Site Visits (OSVs) after that date will utilize the November 2014 version as the assessment framework. To ensure compliance with the most current requirements, it is important that all health centers review the updated Guide and revise their particular policies and procedures as necessary.

HRSA Completes Analysis of Scope Alignment Validation Submissions and Announces Next Steps

In its Primary Health Care Digest dated November 19, 2014, the Health Resources and Services Administration (HRSA) announced that it had completed its analysis of the Scope Alignment Validation (SAV) submissions and is ready to take the next steps in the process to correct health centers’ scope of project forms (Forms 5A and 5B), consistent with the health center’s SAV submission and related comments. As noted in previous Policy Shop blog entries, this past June and July, HRSA conducted a SAV process – a one-time only opportunity for health centers to ensure that their updated scope forms accurately reflected the current services provided and the sites operated by the health center (and if not, to make limited updates and identify the need for additional changes). To assist health centers in understanding these next steps and in taking any actions required of the center, HRSA published a new document, “Scope Alignment Validation Follow-up Actions,” which describes both key action steps and the associated timelines.

In particular, HRSA will be taking the following actions:

• By November 21, 2014, HRSA will delete from Form 5B sites that were identified by the health center as inactive or as duplicates of other sites already in scope.

• By December 5, 2014, HRSA will add or change the service delivery method for Required Services and delete Additional Services (including Specialty Services) from Form 5A, subject to the changes described below.

• In the coming months, HRSA will be making the following additional changes:
o Correct addresses that did not involve a physical location change.
o Update location types where there was a misunderstanding of the site definition.
NOTE: HRSA has stated that if a health center did not receive a targeted Electronic Handbook notification by November 21 regarding a specific site address or location type correction, the requested correction will not be made through this process; rather, the health center will be required to submit a Change in Scope (CIS) request.

Health centers will be required to address all other changes through the CIS process. These changes include:
• Form 5A: Services: (i) adding Additional Services (including Specialty Services) not currently reflected on Form 5A or adding services to Column I and/or II if currently only provided via Column III; and (ii) making any changes to services that are projected to begin at a future date.
• Form 5B: Service Sites: (i) adding or replacing sites (including physical location change); (ii) changing a site from an administrative-only site to a service delivery site; and (iii) changing data fields that were not SAV-related updates.
• Form 5C: Other Activities (changed via a Monitored CIS request): adding or moving an Other Activity to 5C that was incorrectly listed on Form 5A or 5B.
• Other changes: (i) changes needed in cases where HRSA was unable to determine what a health center was specifically requesting as part of its SAV submission comments; and (ii) changes identified after the SAV submission.

All health centers should review this new guidance document along with their scope forms to determine whether changes were made consistent with their SAV submissions and the guidance (and to identify areas where inconsistencies exist), as well as to determine whether additional actions must be taken by the health center.