To qualify for an incentive payment, an EP must have at least 30 percent patient encounters (20 percent for pediatricians) over a selected 90-day reporting period. EPs can report their individual patient volume, or if they are part of a large practice group they can attest using the group’s patient volume. To attest using group volume, certain guidelines must be met:
- Payment assignment: A provider can assign payment to themself, even though they are attesting using group volume.
- “All in / All out” rule: All attesting EPs in a group must use the same patient volume calculation method. When a group practice chooses to use the group patient volume calculation, all attesting EPs in the group must use the group volume. It is not possible for some EPs in the group to use their individual volume and others to use the group volume. However, if an EP practices at multiple locations, the EP can choose to not participate in one group’s attestation, but instead participate with another group they practice with or on their own if they also have a private practice. In this case, the EP could include the EP’s volume as part of one group calculation, but the EP could not count their volume from that practice or a solo one when they attest with another group.
- All Medicaid encounters included in patient volume: When calculating patient volume, all Medicaid encounters that are seen at the group location are included for every practitioner in the group/clinic, even those who are not eligible for the program, or those who are not participating. If the encounter is outside the group practice, do not include it in the calculation.
- Encounters can only be used once: Medicaid encounters used in the patient volume calculation cannot be used for calculating volumes for another practice or individually.
- First person in group to attest: The first person in the group to attest is responsible for selecting the group Texas Provider Identifier number from the list of Group TPIs matching the tax ID on the account. From there, the first person attesting will enter the reporting period and group volume (numerator and denominator), and upload the necessary documentation. Each subsequent person in the group to attest will select the group they are attesting with, attest to information provided by the first person in the group, and provide other required information pertaining to their individual attestation.
- Volume Reporting Period: The volume reporting period is based on any continuous full three-month period or 90-day period in the previous calendar year or in the most recent 12 months before attestation. For EPs using the group patient volume calculation, all EPs in the group will have the same reporting period.
- Out-of-state patient volume: If an EP includes out-of-state patient encounters in the patient volume calculation (optional), the EP is required to indicate which state(s) are being included and upload supporting documentation. If out-of-state encounters are included in the numerator, they must also be included in the denominator.
- Consent from all members of the group: The first EP in a group who attests to group volume is required to upload a Group Volume Consent Form (PDF). The form demonstrates that all providers in the group are aware their patient encounters are being used to calculate the group patient volume. Once a provider’s encounters have been counted with the group, they cannot be counted for a separate attestation by an individual provider.
- Auditable source of data/information: All EPs must ensure they have an auditable source for the volume data entered and attested to.
Calculating Medicaid Patient Volume
Note: Multiple visits for the same day and service only count once. Encounters from the Children’s Health Insurance Program cannot be counted with Medicaid encounters in the numerator. CHIP encounters must be counted in the total patient encounters number (denominator).
The EHR Incentive/PI Program portal takes EPs through a step-by-step process to calculate Medicaid patient volume. To calculate the Medicaid encounter percentage for an EP’s 90-day reporting period, add up total Medicaid encounters (excluding CHIP) during the reporting period and divide by total patient encounters for the reporting period, then multiply the result by 100:
Medicaid patient volume =
(Total Medicaid Patient Encounters ÷ Total Patient Encounters) x 100
If an EP is attesting using group volume, all EPs in the group will have the same Medicaid patient volume percentage and will use the same formula while including all Medicaid encounters across the entire group and all total patient encounters.
* Use all Medicaid encounters from all practitioners in the group, even those not eligible for incentives and those who chose not to participate.
** Use all patient encounters from all practitioners in the group, even those not eligible for incentives and those who chose not to participate.
Meaningful Use/Promoting Interoperability Measures
The Centers for Medicare & Medicaid Services established the Stage 1 Meaningful Use(MU) measures and requirements in 2012. Over the years, CMS has made changes to MU Stages 1, 2 and 3. Starting in program year 2018, MU measures are also now referred to as Promoting Interoperability measures. CMS maintains the latest MU/PI information and measure specifications for each year on their website.