The New HIPAA Privacy and Security Amendments
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Transcript The New HIPAA Privacy and Security Amendments
HITECH Act and EHR
Stimulus Payments
Gerald “Jud” DeLoss
Susan E. Ziel
Disclaimer
This content is provided for general
information purposes and is not intended
as legal advice. Competent legal counsel
should be sought before taking any action
in reliance on this content.
Copyright © 2010
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Background and History
Health Information Portability and Accountability
Act of 1996
Privacy Regulations (2003)
Security Regulations (2005)
American Recovery and Reinvestment Act of
2009 (“ARRA”) (2/17/09)
Title XIII: Health Information Technology for Economic
and Clinical Health Act (“HITECH”)
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CMS EHR Meaningful Use
Notice of Proposed Rule-making (NPRM)
announced December 30, 2009 and published
January 13, 2010
NPRM comment period closed March 15, 2010
Separately, on January 13, 2010, Office of the
National Coordinator (ONC) issued Initial Set of
Standards, Implementation Specifications, and
Certification Criteria for EHR Technology
On March 10, 2010, ONC issued NPRM on
establishment of certification programs for HIT
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Overview of EHR Incentive
Program NPRM
Defines “meaningful use” for purposes of
qualifying for incentive payments and
avoiding reductions
Medicare
Medicare Advantage
Medicaid
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Key Items for Incentives
Medicare and Medicaid are distinct programs
Key Distinctions
Eligibility differs
Payment structures and amounts are different
Incentive payments may be available sooner through
Medicaid
Medicaid programs will depend upon State actions
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Eligible Professionals
Medicare Eligible Professionals (EPs)
Doctors of osteopathy (D.O.s), medical doctors (M.D.s), dentists, podiatrists, optometrists,
and chiropractors
Medicare Advantage (MA) Eligible Professionals (EPs)
Medicare EP who is either
Medicaid Eligible Professionals (EPs)
M.D.s, D.O.s, dentists, certified nurse midwives, nurse practitioners, and physician assistants
in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) led by a
physician assistant
Hospital-based professionals are excluded
Employed by a qualifying MA organization
Employed by or a partner of an entity that through a contract with a qualifying MA organization
furnishes at least 80% of entity’s Medicare patient services to enrollees of the MA organization
Exclude EPs who furnish 90% or more of their covered professional services in an inpatient
hospital, outpatient hospital, or emergency room of a hospital.
Site of service code used for determination
Medicaid providers practicing predominantly in an FQHC or RHC are not subject to the
hospital-based exclusion
An EP is identified by his/her unique National Provider Identifier (NPI)
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MA EPs
MA EPs must meet threshold
requirements
Furnish at least 80% of professional services
covered under Medicare to enrollees of a
qualifying MA organization
Furnish on average at least 20 hours per
week of patient care services to enrollees of
the qualifying MA organization during the
reporting period
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Medicaid EPs
Medicaid EPs must meet one of the
following for each year he/she is seeking
incentive payment
Minimum of 30% Medicaid Patient Volume
Pediatrician with a minimum of 20% Medicaid
Patient Volume
Over 50% of patient encounters in a FQHC or
RHC and have minimum of 30% of volume be
attributable to Needy Individuals
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Eligible Hospitals
Medicare
“Subsection (d) hospitals” that are paid under the hospital
Inpatient Prospective Payment System (IPPS)
Includes Medicare FFS and MA participants and Critical Access
Hospitals (CAHs)
Psychiatric, rehabilitation, long term care, children’s, and cancer
hospitals are excluded
Medicaid
Only acute care hospitals and children’s hospitals are eligible
hospitals
A hospital is determined by its unique CMS Certification
Number (CCN)
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MA Eligible Hospitals
MA Affiliated Eligible Hospitals are EHs
Under common corporate governance with a
qualifying MA organization
More than 2/3 of Medicare beneficiary
patients are enrolled under MA plans
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Medicaid Eligible Hospitals
Medicaid Eligible Hospitals are EHs
Acute care hospital must have at least 10%
Medicaid Patient Volume for each year
Children’s hospitals are exempt from a Patient
Volume threshold
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Program Selection
Eligible Professionals may participate in only
one program: Medicare or Medicaid
A one-time only switch between programs is
permitted prior to 2015
If eligible, hospitals may participate in both
programs simultaneously
If a provider serves a multi-state population and
participates in the Medicaid program, the
provider can participate only in the Medicaid
incentive program through a single State in any
year
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Certified EHR Technology
Certification criteria as set forth by ONC
Even if EHR satisfies those requirements, if not
certified, then not sufficient
Options for EHRs
Complete EHR: All-in-one EHR solution that is
certified to meet all criteria
EHR Module: Any service, component or
combination thereof that is certified to meet at least
one criterion
May include, software as service, interface allowing
participation in health information exchange, quality measure
reporting service
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Certified EHR Technology
Utilization of EHR Modules
It is the responsibility of the EP or EH to ensure that
EHR modules are certified
Each EHR Module certified
All criteria among modules certified
Utilization of Certified EHR Technology
Limited to qualifying for incentives
Does not mean all HIPAA or other legal requirements
are satisfied
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Meaningful Use Stages
Meaningful Use defined in three stages
Stage 1 -- deadline 2011
Capture health information in coded format
Use information to track key clinical conditions and
communicate for care purposes
Implement clinical decision support
Report clinical quality measures and public health information
Stage 2 -- deadline 2013
Likely require the exchange (transmission and receipt) of
data
Stage 3 -- deadline 2015
Criteria expected to target more systemic health care
improvements
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Stages
Progression through Stages
First
Payment
Payment Year
Year
2011
2012
2013
2014
2011
Stage 1 Stage 1 Stage 2 Stage 2
2012
Stage 1 Stage 1 Stage 2
2013
Stage 1 Stage 2
2014
Stage 1
2015
2015
Stage 3
Stage 3
Stage 3
Stage 3
Stage 3
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Stage 1
Improve quality, safety, and efficiency of
healthcare and reduce disparities
Engage patients
Improve care coordination
Improve public health
Ensure privacy and security of PHI
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Stage 1 Criteria
Eligible Professionals
25 objectives and measures
8 measures require “Yes” or “No” as structured data
17 measures require usage of numerator and
denominator
Eligible Hospitals
23 objectives and measures
13 measures require numerator and denominator
Reporting period is 90 days for year one and
one year thereafter
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Quality Measures
Preventive care and screening
Blood pressure management
Drug avoidance among elderly patient
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Quality Measures for Specialty EPs
Specific quality measures
Cardiology
Podiatry
Radiology
Gastroenterology
Neurology
OB/GYN
Ophthalmology
Primary Care
Nephrology
Pediatrics
Nephrology
Endocrinology
Oncology
Psychiatry
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Quality Measures for EHs
EHs under Medicare/MA to report
summary data to CMS
EHs under Medicaid to report directly to
states
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Incentive Payments
Eligible Professionals
75% of charges for Medicare-covered services for the
year, capped at annual maximum
Cap depends on:
Year in which provider first qualified for the incentive payment
(first payment year)
Number of years the provider has earned the incentive
Providers who furnish services in a geographic
Health Professional Shortage Area (HPSA) are
eligible for a 10% increase
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Medicare Payments to EPs
Highest payments to early adopters (2011 and 2012),
with gradual reduction
Calendar Year
First Calendar Year in which EP Receives an Incentive Payment
2011
2012
2013
2014
2015 +
2011
$18,000
-
-
-
-
2012
$12,000
$18,000
-
-
-
2013
$8,000
$12,000
$15,000
-
-
2014
$4,000
$8,000
$12,000
$12,000
-
2015
$2,000
$4,000
$8,000
$8,000
$0
2016
-
$2,000
$4,000
$4,000
$0
Total Potential
Incentive
Payment
$44,000
$44,000
$39,000
$24,000
$0
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Payment Timing
Payment Years
For Medicare EPs, a payment year is a calendar year beginning
on January 1, 2011
For Eligible Hospitals and critical access hospitals, the federal
fiscal year -- FY 2011 begins on October 1, 2010
For Medicaid programs, payment availability can begin as early
as October 2010
For purposes of incentive payments, the first payment
year is the year for which the first incentive payment is
received
First Medicare payment for EPs can be no earlier than
January 2011 and EHs October 2010
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Eligible Hospital Payments
Formula
Primarily focused on hospital discharges
Also factors in Medicare share, which considers the amount of charity care, and
percentage of Medicare-covered inpatient days related to the hospital’s total
number of inpatient days
Discharges will vary based on numbers of discharges in the year, between a floor
of less than 1,150 discharges and a ceiling of 23,000 discharges
Hospitals may qualify for financial incentive payments for four consecutive
years
Incentive payments will be reduced each year
The first year, 100% of calculated incentive payment
In the second year, only 75%
50% in the third year
25% in the fourth year
Hospitals that become meaningful users later (after FY 2013) will either
receive reduced payments or be ineligible for any incentives
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Medicaid EP Payments
85% of “net average allowable costs” costs for EHR
“Net average allowable costs” is term to be defined by Secretary
“Net average allowable costs” capped at $25,000 for first
year and $10,000 in each of five for subsequent years
Pediatricians with under 30% Medicare patient volume may
receive only 2/3 of these amounts
Maximum incentive of $63,750 (85% of $75,000), over a
6-year period
Medicaid EPs must begin receiving incentive payments
no later than CY 2016
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Medicaid Eligible Hospital
Payments
Payments are similar to the calculation for
Medicare hospital incentive payments
Incentive amount calculated using an EHR amount
multiplied by Medicaid share
EHR amount largely based on discharge volume
States may pay up to 100% of the aggregate
EHR hospital incentive amount over a minimum
of a 3-year period and a maximum of a 6-year
period
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Planning for Payments
Strategies for maximizing incentive payments
EHR adoption generally takes 1 ½ to 2 years
Start the selection process now
Determine which program best suits you
Vendors will be hard-pressed to meet deadlines
Ensure that contracts are tightly written
Engage legal team and consultants to ensure
technology, certification, and eligibility
requirements are met
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Questions?
Gerald “Jud” DeLoss
(312) 423-9307
[email protected]
Susan Ziel
(317) 238-6244
[email protected]
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