PAGE 4 KAREO | CONFIDENTIALHow to Participate Today…
PAGE 5 KAREO | CONFIDENTIALHow to Participate Today…Type your questionsArrow opens andcloses your panel
PAGE 6 KAREO | CONFIDENTIALHow to Participate Today…Follow us on Twitter@GoKareoWe’ll be tweeting live usingthe hashtag #KareoTipJoin our other social media channels forconstant updates!
PAGE 7 KAREO | CONFIDENTIALOur Schedule for Today…1 Introduction & Welcome Barbara2 What Small Medical Practices Need toKnow about Meaningful Use Now3 Discover Kareo’s Role4 Answer Questions
PAGE 8 KAREO | CONFIDENTIALBarbara Drury, BA, FHIMSS Health information technologyconsultant Speaks and writes on office-basedcomputer systems for groups likeMGMA, HIMSS, & AHIMA Appointee to the ONC’s TechnicalExpert Panel on UnintendedConsequences of HIT adoption Fellow of the Healthcare Informationand Management Systems Society Serves on the HIMSS Public PolicyCommittee Recipient of the December 2004 andApril 2009 Spirit of HIMSS awardBarbara Drury, BA, FHIMSSPresident, Pricare, Inc.email@example.com
PAGE 9 KAREO | CONFIDENTIALOur Schedule for Today…1 Introduction & Welcome Barbara2 What Small Medical Practices Need toKnow about Meaningful Use Now3 Discover Kareo’s Role4 Answer Questions
PAGE 10 KAREO | CONFIDENTIALDisclaimers• Only Eligible Professionals (EP)• Mostly Medicare, not MA, MCD• Not Interactions between the MU program, PQRS,ACO, eRX, SGR, Sequestration, etc.• Not combo situations (MCD program w/MCR PFS)• Rules are a starting point. CMS and ONC FAQs willclarify nuances and change frequently• The IFR for Certification is related but not addressedhere since it is addressed towards EHR vendors
PAGE 11 KAREO | CONFIDENTIALLearning Objectives• Genealogy of “Meaningful Use”• Meaningful Use “basics”• MU2 Interim Final Rule (IFR) impact on MU1• Money stuff: Maximum Incentives and Penalties• Discussion
PAGE 12 KAREO | CONFIDENTIALThe Grand Plan• The government wants to incent providers to useelectronic health record (EHR) systems.• The government wants evidence that providersare using EHRs for particular things.• Accepting the incentive from the government isoptional, not required.
PAGE 13 KAREO | CONFIDENTIALWhat and Who Is Crafting Meaningful Use• Congress and the President = The LAW: ARRA– American Recovery and Reinvestment Act,aka Stimulus Bill, HITECH Act (section).• Health & Human Services, Centers for Medicareand Medicaid Services (CMS)– Secretary Sebelius– The National Coordinator, currently Dr. FarzadMostashari– The HIT Policy and the HIT Standards Committees– Multiple Work Groups of Volunteers
PAGE 14 KAREO | CONFIDENTIALHow Does This Work?American Recovery and Reinvestment Act. Public Law111-5• Congress and the President.• Stimulate Economy (jobs, mortgages, unemploymentbenefits, “HITECH”).• February 17, 2009 signed into law.• Only changed by Congress.1. THE LAWWork Groups, Staff, hold hearingsto inform the proposed rule.
PAGE 15 KAREO | CONFIDENTIALHow Does This Work?Meaningful Use January 13, 2010 fromHHS/CMS2. THE proposed RULEPublic Comment Period ends.HHS considers comments1. THE LAW
PAGE 16 KAREO | CONFIDENTIALHow Does This Work?Meaningful Use, Certification, Privacy &Security, etc.2. THE proposed RULEFurther guidances to clarify the interim final rule1. THE LAW3. THE INTERIM final RULE
PAGE 17 KAREO | CONFIDENTIALHow Does This Work?Customarily 60 days after the InterimFinal Rule, but sometimes sooner orlater or never (DEA on erx).2. THE proposed RULE1. THE LAW3. THE INTERIM final RULE4. THE effective DATE
PAGE 18 KAREO | CONFIDENTIALWhy Should You Care?• Implementing and using an EHR is a life-changing event.• An EHR may or may not be advantageous.• Electronic records are considered ‘expensive’.• Other players may expect you to use an EHR:– Your customers (the patient)– Your staff and peers– Hospitals, payers, etc.– Public health agencies
PAGE 19 KAREO | CONFIDENTIALWho May Earn the Incentive?• EP = eligible professional– Individual physicians, not practices– Doctors, not mid-levels (some rural exceptions)– Non-hospital based plus hospital-employed physicians working inambulatory clinics (POS 11)• Linked to either Medicare or Medicaid– Medicare FFS maximum = 75% of allowable charges– Medicaid fixed amounts per year provided EP meets eligibilitythresholds ( >30% for all, >20% for peds), no eligibility threshold forMedicare.– Medicare Advantage if 80% of revenue comes from MA. If not, thenMCR FFS or MCD applies• Change incentive program once – from MCR to MCD orMCD to MCR, or MA to either MCR PFS or MCD.
PAGE 20 KAREO | CONFIDENTIALThe Carrots• Incentive paid after the fact.• This “maximum” could be less if youdon’t bill ‘enough’ in that year.• Medicare: Demonstrate MeaningfulUse met throughout all periods.• Medicaid differences:– Year 1: shop and implement– Year 2: demonstrate Meaningful Usethroughout years 2 through 6.– Administered by the state.– Appeal process mandatory.
PAGE 21 KAREO | CONFIDENTIALMaximum Available for MCR FFS Program?MCR PFS $44,000 if MU all 5 yearsWhat time is it in “MU-Land”? Q2-2013 with $15,000 incentiveavailable for Yr 1 if in 2013 calendar year, the EP bills at least$20,000 to original Medicare. If Y3 in 2013, then MCR mustequal $10,667 to earn $8000 (75% of $10,667 = $8000).
PAGE 22 KAREO | CONFIDENTIALMaximum Available for MCD Program?MCD $63,750 if MU at least 6 out of 10 years(goes out to 2021)
PAGE 23 KAREO | CONFIDENTIALAre You…..In a health professional shortage area?• You may get more money.A pediatrician with 20% to 29% Medicaid visits?• You may get less money.Less than 80% revenue from Medicare Advantage?• You’ll need to consider MCR FFS or MCD incentives.You were still using paper charts through 2012?• You will get less money.Sticking with paper charts because ……?• You cannot participate in the incentive programs and beginning2015, Medicare will pay less.
PAGE 24 KAREO | CONFIDENTIALLearning Objectives• Genealogy of “Meaningful Use”• Meaningful Use “basics”• MU2 Interim Final Rule (IFR) impact on MU1• Money stuff: Maximum Incentives and Penalties• Discussion
PAGE 25 KAREO | CONFIDENTIALKey Lingo When Discussing MU> Year> Stage> ARRA $$$> Report Period> MCR Fee %= 1st, 2nd, 3rd= MU1, MU2, MU3, MU4, etc.= Maximum incentive available= 90 days, 365 days, quarter= % of MCR PFS each EP is paid
PAGE 26 KAREO | CONFIDENTIALSome Timing Concepts to RememberMU1-2014MU 2-2014MU1-2013MU1-2012MU1-20112013 CY:Vendor’scapability topermit options for2013 with the2011 Edition?Is one option more advantageous for your patients and thepractice? Do you KNOW what your denominator metric is? Willyou be able to ‘pick’ which denominator is to your advantage?2014 CY:Vendor’scapability topermit options forMU1 with the2014 Edition?2011 Edition Vendor’scapability is based onMU1 as defined inIFR of July 2010.
PAGE 27 KAREO | CONFIDENTIALTidbits: the Numerator, Denominator ThingDENOMINATOR IS: All VisitsAll PatientsAll Orders MCR POS 11 Allowable $MD #1: 100 appts/week, few repeat customers 5200 2600 3900 14,000$ MD #2: 100 appts/week, mostly repeat customers 5200 870 13000 300,000$ THRESHOLD All VisitsAll PatientsAll OrdersMD #1: 50% 2600 1300 1950MD #2: 50% 2600 435 6500EHR Incentive in a $12k yearMax Incentive based on MCR POS 11 Allowable $MD #1: EHR Incentive $ 10,500 MD #2: EHR Incentive $ 12,000 PS: Numerator andDenominator arepayer agnostic.
PAGE 28 KAREO | CONFIDENTIALMore MU Lingo to Understand• MEASURE describes the calculation and minimumthreshold you must achieve to meet the particular Coreor Menu Set Measure• CORE or MENU SET means– Core = all are required to be met– Menu Set = you can pick, with some pre-set requirements, whichMeasures in the Menu Set you will report on.• OBJECTIVE is a description of what you need to ‘do’with the EHR• EXCLUSION is CMS’s ‘pass’ if something doesn’t applyto your EP and your specialty. Some MEASURES haveNO Exclusions.
PAGE 29 KAREO | CONFIDENTIALStage 1 (MU1) SamplesCORE MEASURE: Recordsmoking statusOBJECTIVE: Recordsmoking status for patients13 years old or older.MEASURE: More than 50percent of all unique patients13 years old or older seenby the EP have smokingstatus recorded asstructured data.EXCLUSION: Any EP whosees no patients 13 years orolder.MENU SET MEASURE:Immunization Registries DataSubmissionOBJECTIVE: Capability to submitelectronic data to immunizationregistries and actual submissionaccording to applicable law andpractice.MEASURE: Performed at least onetest of EHR’s capacity to submitelectronic data to immunizationregistries and follow up submissionif the test is successful (unlessnone of the registries has thecapacity to receive the informationelectronically).EXCLUSION: An EP whoadministers no immunizations.
PAGE 30 KAREO | CONFIDENTIALSome Measures have “children” Measures(Measure 10 – Report Clinical Quality Measures to CMS – choose 6 from 44)shaded shows CQMs for all specialties. Differencesbetween MU1 and MU2 CQMs.NQF #MU1: Table 6 for EPs 2011‐2013MU2: Table 8 for EPs CY2014Clinical Quality Measures for Submission by EPs (2011‐2013, choose 6 from CORE/AltCore. If NA, then fill in from other 38). (2014‐pick 9 from 3 domains)0421 Q‐CORE Adult CoreAdult (18 yrs +) BMI and Follow‐up Plan in past 6 months or current visit0013 Q‐CORE out for MU2Adult (18 yrs +) VISITS for patients with diagnosis of hypertension0028 Q‐CORE Adult CoreAdult (18 yrs +) Tobacco Assessment and Cessation intervention within past 24 months0041 Q‐CoreALT6 mos and upInfluenza Immunization for >= 50 years old Sept through February0024 Q‐CoreALT Peds CoreChild (2 to 17 yrs) BMI and Follow‐up Plan during measure year0038 Q‐CoreALT Peds CoreTwo‐year old Immunization Status by second birthday (nine rates)
PAGE 31 KAREO | CONFIDENTIALCQMs (Clinical Quality Measures)• If a CQM is found to be scientifically invalid, wouldtake immediate action to remove without therulemaking process, approximately annually.• Look for CQMs that have an NQF #. Without, maymean electronic specifications are still indevelopment• MU1&2: must submit numerator/denominator. Nothreshold required.• MU2: must be calculated by the CEHRT andreported exactly as generated by the CEHRT,even if not all relevant data is recorded in theCEHRT
PAGE 32 KAREO | CONFIDENTIALCQMs, continued• MU2: must only report on CQMs that the EHR iscertified for. If not certified for NQF 0049 then EPcannot report on NQF 0049. CQM an importantrule out when choosing EHR.• The EHR Vendor will choose which CQMs itwants to be certified for (MU1 not all 44 arerequired for certification, minimum of 9. MU2 notall 64 are required for certification, minimum of 20)• The CEHRT must capture, export, electronicallysubmit accurate data elements as specified in theCertification IFR
PAGE 33 KAREO | CONFIDENTIAL 33Cardiology =1 of 11Peds =2 of 3OB/Gyn =3 of 7Meets “minimum 9 of 44 CQMs”
PAGE 34 KAREO | CONFIDENTIALLearning Objectives• Genealogy of “Meaningful Use”• Meaningful Use “basics”• MU2 Interim Final Rule (IFR) impact on MU1• Money stuff: Maximum Incentives and Penalties• Discussion
PAGE 35 KAREO | CONFIDENTIALClarifications for MU1 in the IFR for MU2• This IFR was effective upon publicationin Federal Register: 9/4/12.• Reaffirmed that if less than 75% of allEPs in US are meaningful users by2015, then MCR penalties can go up to5% (95% of full allowable PFS)
PAGE 36 KAREO | CONFIDENTIALClarifications for MU1, Part 2• MU1 allowed ‘picking’ a menu option and thentaking the exclusion for that same menu option.Beginning in 2014, if still MU1, then OK toclaim an exclusion but MUST pick another fromthe Menu options for MU1.• Makes a clarification between Stages of MU(MU1 and MU2) and ‘edition’ of the certifiedEHR (2011 edition or 2014 edition)• Clarified that for some measures, in the year2014, the measure will be the same for MU1and MU2
PAGE 37 KAREO | CONFIDENTIALClarifications for MU1, Part 3• Leaving a ‘list’ blank does not qualify, i.e.”noallergies”, “no medications”, “noproblems/diagnoses”• CPOE for MU1 = medication orders for‘patients’ – the denominator was patients.Alternate denominator for MU1 year is‘medication orders’• Vitals for MU1 = H/W/(BMI)/BP. Alt. for 2013MU1, option H/W/(BMI) or BP. Exclusion is ifnot relevant, not if you don’t have a scale or BPcuff. Ask referring provider, ask patient is OK.Ages 3 and up. Also rolled into 2014 forward.
PAGE 38 KAREO | CONFIDENTIALClarifications for MU1, Part 4• Test of Exchange for MU1 = in for 2011, in for 2012,out for 2013 of MU1 (on-going required).• If 2014 is still MU1, then ‘electronic copy to patient’is removed and ‘timely access’ is removed. MU1beginning in 2014 will be replaced with “view online,download, and transmit”. Means portal in 2014 forMU1 if late adopter (Yr 1 = 2013, or Yr 1 = 2014)• Public Health Objectives (Immunizations orSyndromic Surveillance, 1 of 2 in menu set). Added“except where prohibited by law”; if not prohibited,then pick one. CMS thinks everybody ‘should’.
PAGE 40 KAREO | CONFIDENTIALLearning Objectives• Genealogy of “Meaningful Use”• Meaningful Use “basics”• MU2 Interim Final Rule (IFR) impact on MU1• Money stuff: Maximum Incentives and Penalties• Discussion
PAGE 41 KAREO | CONFIDENTIALSome Incentive $$$ FYIs• At HIMSS Policy Summit, 9/12/2012, Dr.Mostashari said the incentives were,basically, an entitlement program: you do,therefore you get.• Fine print in ARRA – each year’s incentiveis a maximum, not a guarantee– Sequestration (budget cuts across the board) andSGR can impact the max
PAGE 42 KAREO | CONFIDENTIALMAXIMUM Allowable Charges for Incentive Calc 0.7590 days of charges365 days of charges $ 24,000 $ 18,000 Yr 1 + 2014all other years of MU $ 20,000 $ 15,000 Yr 1 + 2014all other years of MU $ 16,000 $ 12,000 Yr 1 + 2014all other years of MU $ 10,667 $ 8,000 Yr 1 + 2014all other years of MU $ 5,333 $ 4,000 Yr 1 + 2014all other years of MU $ 2,666 $ 2,000 Yr 1 + 2014all other years of MU365 daysof MU, 365days ofchargesLinks: Period, Charges, Amounts in MCR90 days ofMU, 365days ofcharges
PAGE 43 KAREO | CONFIDENTIALIncentive or Penalty (for a $12k year)EHR Reporting Period Lots of MCR Smidge MCRAllowable Charges $ 100,000 $ 13,000 Maximum Incentive $12k is up to 75% of $16k $ 16,000 $ 16,000 Maximum Incentive = $ 12,000 $ 9,750 IncentiveVERSUSAllowable Charges $ 100,000 $ 13,000 LESS Penalty (98% of fee schedule) $ (2,000) $ (260) PenaltyNET Allowable Charges $ 98,000 $ 12,740 Lots of MCR Smidge MCR"….to EHR, or" 12,000$ 9,750$ "not to EHR" (2,000)$ (260)$ • To EHR: costs,workflow changes,people impact• Not to EHR: stuckon penalty step,other payersparticipation, othermembers of the careteam, patients
PAGE 44 KAREO | CONFIDENTIALShow me the $$$ (or not?)• Begins 2015 and goes from 100% PFS in 2014 to 99% in2015, 98% in 2016, 97% in 2017.• Once a penalty is applied, you can never go back to 100%but are stuck at that penalty level.• Applies to entire PFS, not just office encounters• If less than 75% of the US EPs are NOT MUs in 2017,then 96% in 2018, 95% in 2019.– Hospital-based EPs are excluded from the 75%• CMS look-back is generally two years prior, or July 1stprior to penalty year– Avoid overpayment and refund issues with CMS systems andbanking– Avoid beneficiary over/under co-insurance issues
PAGE 45 KAREO | CONFIDENTIALHardship Exemptions• Case-by-case by Secretary of HHS, max of 5years by law, designated annual by the IFR• No exemption for EPs over 60, or for part-timeEPs• Identified Hardships in IFR– Lack of internet (4mb), annual re-apply– Newly-practicing EP gets 2 years from EP date (changingspecialty does not count)– Scope of practice: i) no face to face w/patients or no follow-up needed, anesthesiology, pathology, radiology in non-hospital settings (5 years), ii) 50%+ in ASC or NH w/oCEHRT, (1 year)
PAGE 46 KAREO | CONFIDENTIALOther Hardships Identified• Extreme Hardships listed:– Practice closes– Hospital closes– Natural disaster that “destroys EHR”– EHR vendor out of business– EHR vendor unable to get certified for next stage– EP in a debt consolidation or bankruptcy process• IFR recommends if anticipating any of these in2013, apply to the Secretary in early 2013 toavoid penalty in 2015
PAGE 47 KAREO | CONFIDENTIALPenalty Timing Concepts (for MCR)ARRA $$$IncentiveYears1 2 3 4 5ARRADrop-dead$$$ Year2016 last ARRApayment if startedby 2014MCRPenaltySTARTS2015 MCRPenalty99% ofPFS3 4 5 6 72-yearlook-backfor MUNOTE: Dip-in, Dip-out doesn’t stop the Incentive $$$ countdown6MUST adoptno later than2014
PAGE 48 KAREO | CONFIDENTIAL‘Playing’ Medicare Penalty BINGO• Cell colors: Green = Stage 1 (MU1), Yellow = Stage 2 (MU2),Light red = Stage 3 (MU3), Grey = Stage 4 (MU4)• Order of text within cells (upper right double-lined cell)– Participation Year (YR 1, YR 2, YR 3, etc.)– MU Stage (MU1, MU2, MU3, MU4, MU5 (really!))– ARRA Incentive $$$ (at maximum)– EHR Reporting Period (90 day or 365 day)– Medicare PFS either 100%/na/no penalty or 99%, 98%, 97%– Comment• Row 6: Example of a dip-in, dip-out EP• Many other variations not shown but can be developed
PAGE 50 KAREO | CONFIDENTIALA Peek at the Impact of the 2% from Sequestration50Visit Calculation No Sequestration With SequestrationBilled to Original Medicare 200.00$ 200.00$ MCR Allowable for 99214 153.00$ 153.00$ Sequestration 2% new allowable ‐$ 149.94$ MCR 80% (122.40)$ (119.95)$ Patient/2nd 20% (30.60)$ (29.98)$ Adjustment down to Allowable (47.00)$ (50.06)$ In a $12k Incentive Year No Sequestration With SequestrationBilled allowable required 16,000.00$ 16,000.00$ # of visits required to generate $16k in allowable charges105 visits @$153 ea 107 visits @$149.94 eaIncentive Earned 12,000.00$ 12,000.00$
PAGE 51 KAREO | CONFIDENTIALWay too much, right?And + or - really does depend onYour perspective (and the ‘others’ from“Who cares?”)
PAGE 52 KAREO | CONFIDENTIALOur Schedule for Today…1 Introduction & Welcome Barbara2 What Small Medical Practices Need toKnow about Meaningful Use Now3 Discover Kareo’s Role4 Answer Questions
PAGE 53 KAREO | CONFIDENTIALDiscover Kareo’s Role“…Make Your Practice a Best Practice!”
PAGE 54 KAREO | CONFIDENTIALDiscover Kareo’s Role• PAHCOM has approved 1 CEU credit.• Each attendee will receive an email today witha link to request certification. Certificates willbe mailed within the next few days.• Attendees must be logged into the webinar toreceive credit.• Questions - email firstname.lastname@example.org“…Make Your Practice a Best Practice!”
PAGE 59 KAREO | CONFIDENTIALDiscover Kareo’s Role
PAGE 60 KAREO | CONFIDENTIALLet’s Answer Your QuestionsIs it too late to think aboutStage 1 attestation?Questions Now 888.775.2736 email@example.comQuestions After the WebinarFor Kareo…For Barbara… firstname.lastname@example.org
PAGE 61 KAREO | CONFIDENTIALWhat Small MedicalPractices Need to Knowabout Meaningful Use Now
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