Meaningful Use

What is meaningful use?

Meaningful use” refers to the objectives established by CMS for the use of electronic health records (EHR) under the Medicare and Medicaid EHR Incentive Programs.  Eligible professionals (EPs) may receive incentive payments, or avoid payment reductions under Medicare, for demonstrating that they are meaningful users of EHR.  These programs are to be implemented in three stages, and providers must demonstrate that they meet the meaningful use criteria in each stage before moving on to the next.  Stage 1 meaningful use is focused on “data capturing and sharing” including demonstrating an ability to electronically record, share, and protect patient health information.  Stage 2 will demonstrate advanced clinical processes, including the use of data for quality improvement and identification of patients in need of follow-up care.  Stage 3 will focus on improving outcomes, with objectives to be determined.  In all three stages, EPs will also have to report on clinical quality measures (CQMs).  2014 will be the first year that EPs may demonstrate meaningful use under Stage 2.  

While providers may be eligible for both the Medicare and Medicaid EHR Incentive Programs, they may only receive incentive payments under one of the two.  Providers who are only eligible for the Medicaid program will not be subject to payment reductions for not participating in the Medicare EHR Incentive program.  But those eligible for both programs who choose to participate in the Medicaid EHR incentive program may be subject to payment adjustments if they do not also demonstrate meaningful use under Medicare by 2015.  What this means as of 2014 is that a provider who would previously have been dually eligible for the Medicare and Medicaid EHR Incentive Programs must comply with the Medicare meaningful use requirements to avoid a penalty but may continue to participate in the Medicaid EHR Incentive Program and earn an incentive payment. Fortunately, the requirements for demonstrating meaningful use for Medicaid are the same as for Medicare, although it applies to a different patient population and the data is reported to the state Medicaid agency rather than Medicare. 

What are the incentives or penalties for showing meaningful use under the Medicare EHR Incentive Program?

The Medicare EHR incentive program is run by CMS and provides a maximum incentive of $43,720, with payments over five years.  Providers must meet objectives in each of these years to receive the full payment.  The maximum incentive payment is only available to those who began participating in CY 2011 or CY 2012.  For providers beginning in CY 2013, a total incentive payment of $38,220 is available with payments spread out over four years.  For those beginning in CY 2014, the incentive payment is reduced to $23,520 total, spread out over three years.  2014 is the last year where new participants may be eligible for an incentive payment.

As of 2015, the program will also allow for “payment adjustments” or reductions to an EP’s total Medicare physician fee schedule (PFS) payments for the year.  Payment adjustments can be as low as 1% or as high as 5% depending on how many years an EP has failed to demonstrate meaningful use.

Finally, EPs may also apply for a hardship exception exempting them from the payment adjustment.  Each hardship exception will be valid for only one year.

What is the EHR Incentive Program for Medicaid?

The Medicaid EHR incentive program is run by CMS and provides a maximum incentive of $63,750 over a six year period.  EPs may receive the maximum incentive payment so long as they sign up by 2016.  There are no penalties at any time under this program.  Payment in the first year of the program is $21,250, and payment for each of the remaining five years is $8,500.  EPs need only adopt Certified EHR Technology (CEHRT) to receive an incentive payment in year 1 but must comply with Stage 1 meaningful use in years 2 and 3, Stage 2 in years 4 and 5, and Stage 3 in year 6.

There are additional eligibility requirements to participate in this program, including having a 30% Medicaid patient volume or having a 20% Medicaid patient volume as a pediatrician.  The program also includes EPs who predominantly practice in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) and have a 30 percent patient volume of needy individuals. For additional information about eligibility, please refer to the CMS Medicaid EHR Incentive program page

What EHR is required?

To qualify for incentives, EPs must use an EHR program “that stores data in a structured format” for easy use and transfer of patient information.  The CMS Office of the National Coordinator for Health Information Technology (ONC) has established standards for EHR to qualify as certified EHR technology (CEHRT).  CMS also provides a Certified Health IT Product List (CHPL) online.  To qualify for the EHR Incentive Program, EPs may need to change their existing EHR.  An EP who has already participated in Stage 1 may also need to update CEHRT for Stage 2.

Due to backlogs in certification and availability of the 2014 CEHRT, CMS issued a proposed rule on May 23, 2014 that would alter the CEHRT requirements for 2014.  Providers who are unable to fully implement the 2014 CEHRT to attest to meaningful use in 2014 would be able to continue to use 2011 CEHRT to attest to Stage 1 and Stage 2 meaningful use objectives, or a combination of 2011 CEHRT and 2014 CEHRT.  By 2015, however, all providers must have implemented the 2014 CEHRT.  The proposed rule is available here.

Who is eligible?

Doctors of medicine or osteopathy are among the eligible physicians for the EHR incentive program.  CMS provides an online tool to help medical professionals determine their eligibility.

Only individual providers may decide to participate in the program, though they may designate their practice to receive incentive payments.  A physician practice cannot choose to participate on its own or on behalf of its EPs, even if the practice owns or purchases the CEHRT used by EPs.  Hospital-based providers, or those that provide more than 90 percent of covered professional services in an inpatient or emergency hospital department, are not eligible.

How do I sign up?

Participants can register online and may also cancel their registration at any time.  Initial registration serves as an assessment of eligibility.

What are the reporting periods?

For the first year of participation, providers must show that they have met all the meaningful use EHR requirements continuously for any 90 day period between January 1 and December 31 of that year.  After the first year, providers must show that they met these requirements for each full year, except for 2014 where no matter what stage of the program an EP is currently participating in he or she will only have to report for a three month period.  This allows all providers to have time to upgrade their CHERT so they may participate in Stage 2.

What are the meaningful use requirements in each Stage?

During Stage 1, eligible professionals must satisfy 13 required or core objectives and 5 of 10 menu objectives of the physician’s choice subject to certain requirements.  All of these objectives are tied to “measures” or standards set by CMS that each EP must meet to satisfy the objective.  Some EPs may also be excluded from meeting some of these objectives, typically where there is a lack of data for a particular objective because of the nature of the physician’s practice.  

Eligible professionals will move to Stage 2 after successfully demonstrating meaningful use under Stage 1 for two years.  For those who are already eligible for Stage 2, there is a new list of core and menu objectives.

EPs must also report a number of CQMs across various National Quality System (NQS) domains to satisfy the meaningful use requirements.  This is merely a reporting requirement, and there are no measures or standards for CQMs.  All providers, no matter what stage of the program they are participating in, are subject to the same CQM reporting rules.  Successful reporting of CQMs under meaningful use also qualifies as successful reporting under the Physician Quality Reporting System (PQRS).  Providers who satisfy this requirement should therefore be able to avoid payment adjustments under both programs.

The release of the Stage 3 meaningful use rules has been delayed until 2017.  For this reason, providers who have already entered or completed Stage 2 by 2015 need only continue to demonstrate Stage 2 meaningful use in 2016.

How does the data get reported?

Physicians must “attest” to having satisfied the above objectives and report on clinical quality measures. The information can be entered into the same online, electronic system sponsored by CMS where the physician first registered for the program.  Physicians who have successfully met the meaningful use requirements will find out immediately upon entering the data into the system.  Physicians can also use an attestation calculator to determine whether they are on their way to meeting the objectives and reporting requirements during a reporting period.  

EPs reporting their compliance with meaningful use requirements in 2014 will report a three month period in the 2014 calendar year.  The calendar year ends on December 31, 2014 and the attestation deadline will be February 28, 2015.  EPs who wish to avoid payment reductions in 2016 must attest by that deadline.  A timeline of deadlines for attestation and reporting through 2016 is available here.  

Can I be audited?

Providers who receive EHR incentive payments can be subject to audits and those found to be noncompliant with the EHR incentive program will have their incentive payments recovered.  CMS may also choose to pursue additional actions against EPs and other providers who fraudulently attest to compliance with the Medicare meaningful use requirements, including the possibility of a suit under the False Claims Act and other Medicare Fraud and Abuse Laws.

For these reasons, EPs should thoroughly document compliance with meaningful use requirements for all years they have attested to such compliance to CMS.  Documentation should be retained for six years after each attestation.  Additional information about this documentation is available here.

Are there other applications of the EHR incentive program?

Eligible hospitals may also be subject to the Medicare and Medicaid EHR incentive program with modified core and menu requirements and reporting requirements to satisfy meaningful use.  Hospital incentives are based on a $2 million base payment that is adjusted based on certain factors.  As of 2015, hospitals that have not demonstrated meaningful use will be subject to payment adjustments.

Medicare Advantage organizations may also be eligible for EHR incentive patients, and EPs and hospitals who are employed or owned by or who otherwise have a substantial relationship with an MA organization will be covered under the MA EHR Incentive program.  Incentive payments under this program are made to the MA Organization directly.  Eligible MA organizations must be licensed as HMOs, or in the same way as HMOs, under state law.

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