CMS and ONC have posted a fact sheet that details progress HHS has made in promoting the growth of health information technology since the enactment of the Health Information Technology for Economic and Clinical Health (HITECH). The fact sheet addresses, among other things, statistics on participation in the Electronic Health Record Incentive Programs and electronic prescribing and information on HHS plans to accelerate health information exchange development.
CMS is reminding eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) attesting to receive an incentive payment for either the Medicare or Medicaid Electronic Health Record (EHR) Incentive Program that they may be subject to a pre-payment or post-payment audit. CMS has provided a fact sheet on supporting documentation for providers selected for such audits.
On May 3, 2013, CMS and the Office of the National Coordinator for Health Information Technology (ONC) are hosting a meeting to discuss electronic health records, the increase in code levels billed for some Medicare services, and appropriate coding in an increasingly-electronic environment. The meeting, which is aimed at providers, health information technology vendors, and other interested stakeholders, will address issues such as the impact of EHRs on high quality clinical care, provider efficiency and coding, and coding challenges and opportunities facing various groups, including hospitals and clinicians. Attendees may participate in person, via telephone, or web streaming. Registration is required.
This post was written by Jennifer Pike.
CMS and the OIG have proposed new rules to extend existing protections that allow hospitals to donate electronic health record (EHR) technology to physicians who refer patients to their facilities. By way of background, in 2006, CMS established an exception to the Stark self-referral law to allow hospitals to donate EHR technology to physicians under certain circumstances. Likewise, in 2006, the OIG established a safe-harbor to protect such EHR donations from enforcement under the federal anti-kickback statute. While both protections are set to expire on December 31, 2013, the proposed rules would extend the provisions until the end of 2016 as a means to facilitate the adoption of EHR technology. The proposed rules also would (1) remove the requirement from the original rule that donated EHR technology contain electronic prescribing capability, and (2) update the provision under which EHR technology is deemed interoperable, which would expand the types of EHR systems that qualify for the protections. Comments on both proposed rules will be accepted until June 10, 2013.
CMS and the Office of the National Coordinator for Health Information Technology (ONC) are seeking comments on a series of potential policies intended to accelerate electronic health information exchange (HIE) across providers. The notice identifies various gaps that the policies and programs are intended to address, such as low rates of electronic health record (EHR) adoption and HIE among post-acute and long-term care providers; low rates of EHR adoption and HIE across settings of care and providers (including ambulatory care, post-acute and long-term care, behavioral health, and lab providers); and low rates of consumer and patient engagement. The notice also includes specific questions for stakeholders, such as what changes in payment policy would have the most impact on the electronic exchange of health information (particularly among organizations that are market competitors); how policies should be developed to maximize the impact on care coordination and quality improvement; how CMS can leverage regulatory requirements for acceptable quality (such as conditions of participation for hospitals or requirements for skilled nursing facilities (SNFs) and home health) to support electronic, interoperable HIE; and how new authorities under the ACA for testing innovative payment and service delivery models can best accelerate standards- based electronic HIE across treating providers. Comments will be accepted until April 22, 2013.
On January 3, 2013, CMS published a request for information from hospitals, electronic health record (EHR) vendors, and other interested parties regarding hospital readiness beginning calendar year 2014 discharges to electronically report certain patient-level data under the Hospital Inpatient Quality Reporting (IQR) Program using the Quality Reporting Document Architecture (QRDA) Category I. While feedback orignially was due by January 22, 2013, CMS subsequently extended the comment deadline until February 1, 2013.
CMS is hosting a national provider call on January 16, 2013 on Meaningful Use requirements under the Medicare and Medicaid Electronic Health Record Incentive Programs. The target audience is hospitals, critical access hospitals, and professionals eligible for incentives. Registration is required.
The Medicare electronic health record (EHR) incentive program is vulnerable to paying incentives to professionals and hospitals that do not fully meet meaningful use requirements due to gaps in CMS oversight, according to a recent OIG report. Based on a review of CMS’s oversight of self-reported meaningful use of certified EHR technology in 2011, the OIG found that CMS did not have strong prepayment or postpayment safeguards. The OIG also noted that CMS cannot use EHR reports to verify all self-reported meaningful use information because the Office of the National Coordinator for Health Information Technology (ONC) does not require certified EHR technology to be capable of producing reports for all measures. As a result of these findings, the OIG recommends that CMS: (1) obtain and review supporting documentation from selected professionals and hospitals prior to payment to verify self-reported information (although CMS argued that this would increase the burden on providers); and (2) issue more detailed guidance on documentation requirements (CMS agreed). The report also contained recommendations for ONC, including recommendations that the agency: (1) require that certified EHR technology be capable of producing reports for yes/no meaningful use measures where possible; and (2) improve the certification process for EHR technology to ensure accurate EHR reports (ONC concurred with both recommendations). For more information, see the full report, “Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program."
The Health Information Technology for Economic and Clinical Health (HITECH) Act provided funding to promote the adoption and meaningful use of certified EHR technology, including a Medicaid EHR program. In 2011, the first year of the Medicaid EHR program, 1,964 hospitals and 45,962 professionals were awarded a total of approximately $2.7 billion in Medicaid EHR incentive payments, according to a GAO report describing the characteristics of providers that participated in the program in 2011. Hospitals claimed $1.7 billion in these Medicaid EHR incentive payments, with a median payment amount of $613,512. Almost half of the hospitals (46%) receiving payments were located in the south, while the smallest proportion (15%) were located in the northeast. Also among hospitals receiving payments, 62% were located in urban areas, 80% were acute care hospitals, 57% percent were nonprofits, and 57% were not members of a chain, while hospitals with the highest number of total beds were twice as likely to receive an incentive payment than those with the fewest number of beds. With regard to professionals, who were awarded a total of $967 million in incentive payments, more than three times as many eligible professionals participated in the Medicaid EHR program than in the Medicare EHR program. The largest proportion of professionals who received a Medicaid EHR incentive payment for 2011 were in the south (37%), compared to 20% in the midwest. As with hospitals, most professionals receiving EHR incentive payments (83%) were located in urban areas. Additional details can be found in the full report, “Electronic Health Records: Number and Characteristics of Providers Awarded Medicaid Incentive Payments for 2011."
On December 7, 2012, CMS published an interim final rule with comment period that updates the Data Element Catalog (DEC) standard and the Quality Reporting Document Architecture (QRDA) Category III standard adopted in a September 4, 2012 final rule. The interim final rule with comment period also revises the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs by adding an alternative measure for the Stage 2 meaningful use objective for hospitals to provide structured electronic laboratory results to ambulatory providers. The regulation also revises regulatory text for measures pertaining to hospitals providing patients with the ability to view online, download, and transmit information about a hospital admission. In addition, the rule addresses the applicability of the case number threshold exemption for clinical quality measure (CQM) reporting to eligible hospitals and critical access hospitals beginning with FY 2013. CMS also announces its intention to issue technical corrections to the electronic specifications for CQMs released October 25, 2012. Certain provisions within the interim final rule are effective January 7, 2013, and comments will be accepted until February 5, 2013.
CMS has scheduled a December 18, 2012 National Provider Call on the Physician Quality Reporting System (PQRS) and Electronic Prescribing (eRx) Incentive Program. The call will provide an overview of the Program Year 2012 Data Submission for the PQRS-Electronic Health Record Incentive Program Pilot and Program Year 2013 self-nomination process for group practice reporting options, registries, maintenance of certification, and electronic health record data submission vendors.
On October 29, 2012, CMS published additional corrections to its August 31, 2012 final FY 2013 Medicare inpatient prospective payment system (IPPS) rule. The corrections address the achievement thresholds and benchmark values presented in the Clinical Process of Care measures section of the final performance standards for the FY 2015 Hospital Value-Based Purchasing Program table. In addition, CMS has published a notice correcting technical and typographical errors in the September 4, 2012 final rule specifying the “Stage 2” meaningful use criteria that eligible professionals, eligible hospitals, and critical access hospitals must meet in order to qualify for Medicare and/or Medicaid electronic health record (EHR) incentive payments.
CMS has posted a set of electronic specifications for clinical quality measures (eCQMs) for eligible professionals and eligible hospitals for use in the EHR incentive program for electronic reporting in 2014.
Hospitals Return Fire After Administration Warns Hospitals Against Gaming Payments through Electronic Health Records
In a letter to five major hospital associations on September 24, 2012, HHS Secretary Kathleen Sebelius and Attorney General Eric H. Holder, Jr., made sweeping generalizations about the improper utilization of electronic health record (EHR) technology to “game the system” to increase reimbursement. In a letter to the associations, Sebelius and Holder tout the benefits of EHR in coordinating care, improving quality, reducing paperwork, and eliminating duplicative tests, but warn that the technology also might facilitate fraud and abuse. Specifically, the letter cites “troubling indications” that some providers are using electronic health care technology to obtain payments to which they are not entitled, by such as by “cloning" medical records to inflate payments or “upcoding” the intensity of care or patient severity. The letter suggests hospitals may be using EHR to cut and paste together different medical records for a single patient, risking both medical errors and overpayments. The letter asserts that “[f]alse documentation of care is not just bad patient care; it's illegal.” Sebelius and Holder express their “resolve to ensure payment accuracy and to prevent and prosecute health care fraud.” To that end, the Administration is stepping up data mining and audits, including more extensive medical reviews to ensure that providers are coding evaluation and management services accurately. In addition to enforcement actions (including payment suspension where fraud is suspected), CMS will consider payment reductions as warranted reductions “to address inappropriate increases in coding intensity.” The letter, which followed a report in the New York Times regarding alleged hospital upcoding of evaluation and management codes, was sent to the American Hospital Association, Federation of American Hospitals, Association of Academic Health Centers, Association of American Medical Colleges, and National Association of Public Hospitals and Health Systems, is posted here.
In a rapid response, the American Hospital Association suggested that CMS shares the blame for a lack of clarity on hospital evaluation and management coding, noting “We have made numerous requests to the Centers for Medicare and Medicaid Services to develop national guidelines for the reporting of hospital emergency department and clinic visits. This is a request the AHA has made to CMS 11 times (starting in 2001) since the outpatient prospective payment system was first implemented.” AHA also rejected the need for more audits, saying, “What's needed is clearer guidance from CMS, not duplicative audits that divert much-needed resources from patient care.” The letter is posted at aha.org. The Association of Academic Health Centers, in a separate letter, also commented on the lack of coding guidance.
The Sebelius-Holder letter is emblematic of the rapidly-deteriorating relationship between providers and the federal government, as reimbursement and policy disputes are too often viewed through the lens of fraud. This relationship is likely to be further strained as Congress and the Administration negotiate alternatives to sequestration that could result in steeper Medicare and Medicaid reimbursement cuts.
CMS Issues Final "Stage 2" Medicare/Medicaid Electronic Health Record (EHR) Incentive Program Rules, EHR Certification Standards
On September 4, 2012, CMS published a final rule specifying the “Stage 2” meaningful use criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and/or Medicaid EHR incentive payments. By way of background, under Stage 1 (which began in 2011), “meaningful use” consists of transferring data to EHRs and being able to share information such as electronic copies and visit summaries for patients (note that certain Stage 1 criteria are modified under the Stage 2 final rule). Stage 2 meaningful use criteria, which are the focus of this final rule, seek to increase the exchange of clinically relevant information between providers and promote patients’ secure online access to their health information. With regard to timing, the final rule provides that any provider who first attested to Stage 1 criteria in 2011 will have until 2014 to attest to Stage 2 criteria (instead of 2013 as provided under the Stage 1 final rule). The final rule also specifies Medicare payment adjustments that will apply beginning in 2015 for covered professional services and hospital services provided by EPs, eligible hospitals, and CAHs failing to demonstrate meaningful use of certified EHR technology and other program participation requirements according to the applicable schedule. CMS adopted certain hardship exceptions to the payment adjustments related to: availability of internet access or barriers to obtaining information technology infrastructure; newly practicing EPs who would not otherwise be able to avoid payment adjustments; unforeseen circumstances such as natural disasters; and certain scope of practice issues, such as lack of face-to-face or telemedicine interaction with patients or lack of control over the availability of Certified EHR Technology at their practice location, to recognize certain barriers concentrated among specialties such as anesthesiology, radiology, and pathology. Looking ahead to Stage 3, under which “meaningful use” will include demonstrating improvement in quality of health care, CMS states in the preamble to the rule that it intends to finalize Stage 3 criteria through rulemaking in 2014, with Stage 3 starting in 2016.
Also on September 4, HHS published a final certification criteria rule establishing the technical capabilities and related standards and implementation specifications that Certified EHR Technology will need to include, at a minimum, to support the achievement of “meaningful use” by EPs, eligible hospitals, and CAHs under the Medicare and Medicaid EHR incentive programs beginning with the 2014 EHR reporting periods. The final rule also makes changes to the permanent certification program for health information technology, including changing the program’s name to the ONC HIT Certification Program. The rule is effective October 4, 2012.
On September 13, 2013, CMS is hosting a call on the agency’s September 4, 2012 final rule on Stage 2 EHR requirements and other changes to the EHR Incentive Programs.
The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule that would update Medicare payment and other policies for the hospital outpatient prospective payment system (OPPS) and ambulatory surgical centers (ASCs) for calendar year (CY) 2013. The proposed rule also would update Medicare inpatient rehabilitation facility (IRF) quality reporting program policies and various other Medicare policies. The official version of the rule is scheduled to be published in the Federal Register on July 30, 2012. CMS will accept comments on the rule until September 4, 2012. Key provisions of the proposed rule include the following:
- The rule would increase 2013 OPPS rates by 2.1% compared to 2012 levels (although the impact on particular procedures would vary). This update reflects a hospital market basket increase of 3.0%, which is reduced under two Affordable Care Act (ACA) provisions – a 0.1 percentage point reduction and an estimated 0.8% “multi-factor productivity” (MFP) adjustment/reduction. The OPPS update is subject to other adjustments, including a 2 percentage point reductions for hospitals that do not meet quality reporting requirements. For 2013, CMS proposes to determine OPPS relative weights using the geometric mean costs of services within an Ambulatory Payment Classification, rather than median costs, which CMS expects would have a limited payment impact on most providers.
- CMS proposes setting OPPS payment for separately payable drugs and biologicals without pass-through status at average sales price (ASP) plus 6% (which it refers to as the “statutory default” rate), compared to the current ASP plus 4%. Notably, CMS is not proposing to make an adjustment for pharmacy overhead costs in 2013 to reflect the redistribution of package costs, as it had for 2010 through 2012. The proposed 2013 threshold for separate payment for outpatient drugs would be a cost per day that exceeds $80, compared to $75 in 2012. CMS also proposes a special payment adjustment policy for radioisotopes derived from non-highly enriched uranium sources.
- With regard to ASC policy, CMS is proposing to increase ASC payment rates by 1.3%, which is derived from a 2.2% inflation update reduced by an MFP adjustment of -0.9%. ASC payment rates for CY 2013 will represent 57% of rates for the same services under the OPPS. CMS is soliciting comments on development of an ASC-specific inflation index in place of the current Consumer Price Index for All Urban Consumers. CMS also proposes changes to the regulations regarding payment for new technology intraocular lens (NTIOLs) in the ASC setting to require more stringent labeling and clinical outcomes evidence to support NTIOL applications.
- CMS proposes changes to the IRF Quality Reporting Program, including updates to the quality measures that will impact annual prospective payment amounts in FY 2014 and procedural changes to the process for updating quality measures.
- In addition, the proposed rule addresses: refinements to the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program; payment for partial hospitalization services; potential changes to the Part A to Part B Rebilling Demonstration; revisions to the electronic reporting pilot for the Electronic Health Record Incentive Program; clarification of the application of the supervision regulations to physical therapy, speech-language pathology, and occupational therapy services furnished in OPPS hospitals and critical access hospitals; and changes to regulations governing Quality Improvement Organizations, including the secure transmittal of electronic medical information, beneficiary complaint resolution and notification processes.
According to the OIG, 57% of Medicare physicians used an electronic health record (EHR) system at their primary practice location in 2011, based on a sample of 2,000 physicians who provided at least 100 evaluation and management (E/M) services in 2010. Almost one quarter of physicians (22%) first began using EHR systems to document E/M services in 2011, the first year of the Medicare EHR incentive payment program. The OIG also reports that 73% of Medicare physicians with an EHR system used a certified system to document E/M services. The OIG speculates that physicians will likely continue to adopt and implement certified EHR technology to avoid Medicare payment reductions starting in 2015.
CMS and ONC are holding a joint National Provider Call on June 27, 2012 to provide information to eligible professionals (EPs) and eligible hospitals on the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. The program also will discuss the use of certified EHR technology to meet the meaningful use standard. Advance registration is required.
CMS has posted the names and addresses of Medicare eligible professionals (EPs), eligible hospitals, and critical access hospitals that have successfully demonstrated meaningful use and received a payment as of March 2012 under the Medicare Electronic Health Record (EHR) Incentive Program. CMS has made more than $2.3 billion in Medicare EHR Incentive Program payments between May 2011 and the end of March 2012.