2018 Medicare Electronic Health Record (EHR) Incentive Program Payment Adjustment Fact Sheet for Eligible Clinicians

2018 Medicare Electronic Health Record (EHR) Incentive Program
Payment Adjustment Fact Sheet for Eligible Clinicians

As part of the American Recovery and Reinvestment Act of 2009 (ARRA), Congress established payment adjustments under Medicare for certain eligible clinicians(eligible clinicians include doctors of medicine or osteopathy, doctors of dental surgery or dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors) that are not meaningful users of Certified Electronic Health Record (EHR) Technology. EPs that do not successfully demonstrate meaningful use for an EHR reporting period associated with a payment adjustment year will receive reduced Medicare payments for that year. The Medicare payment adjustments sunset in 2018 for EPs pursuant to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

If a clinician is eligible to participate in the Medicare EHR Incentive Program, by law they must successfully demonstrate meaningful use in either the Medicare EHR Incentive Program or in the Medicaid EHR Incentive Program, to avoid a downward Medicare payment adjustment. Medicaid clinicians who do not furnish covered professional services under Medicare are not subject to these downward payment adjustments. Since 2011, more than 400,000 clinicians have received incentive payments under the Medicare and Medicaid EHR Incentive Program.

2017 Performance Period and the Merit-based Incentive Payment System (MIPS) replacing EHR, PQRS and VBM programs

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) combines certain aspects of the existing Medicare EHR Incentive Program (EHR), Physician Quality Reporting System (PQRS), and Value-Based Payment Modifier (VBM) programs into the Merit-based Incentive Payment System (MIPS), starting with the 2017 MIPS performance period. MIPS payment adjustments are applied to Medicare Part B payments for items and services furnished two years after the performance period, with 2019 being the payment adjustment year for the 2017 performance period.

By law, MIPS includes four categories of eligible clinician performance, contributing to a MIPS final score of up to 100 points (relative weights are indicated for the 2017 performance period and associated 2019 payment adjustment year):

• Quality (60%)
• Advancing Care Information (renamed from Meaningful Use) (25%)
• Improvement Activities (15%)
• Cost (0%)

For 2017, clinicians who successfully demonstrated meaningful use in a prior year will no longer report to the Medicare EHR Incentive Program, although clinicians who are eligible for Medicaid EHR incentive payments will continue to attest to their state to earn an incentive payment. Clinicians who previously reported under the Medicare EHR Incentive Program will instead report to MIPS for 2017, and are subject to the program requirements and payment adjustments of that program. However, if a clinician has not successfully demonstrated meaningful use in a prior year and wants to avoid the 2018 downward payment adjustment under the Medicare EHR Incentive Program, the EHR reporting period was a consecutive 90-day period in 2017, and the clinician must have attested to meaningful use no later than October 1, 2017. As mentioned above, clinicians who would have been first-time participants in the Medicare EHR Incentive Program in 2017 may have been eligible to apply for a one-time hardship exception by October 1, 2017 in order to avoid the 2018 downward payment adjustment.

EHR Incentive Payments for Eligible Professionals

Eligible clinicians who successfully demonstrated meaningful use of certified EHR technology could have received incentive payments under Medicare for up to 5 consecutive years throughout the duration of the program. The program started in 2011, and payments continued under Medicare through 2016 with no Medicare incentive payments available after 2016 pursuant to the statute.

A clinician demonstrates meaningful use by successfully attesting through either the CMS Medicare EHR Incentive Programs Attestation System (https://ehrincentives.cms.gov) or through its state’s Medicaid EHR Incentive Program attestation system.

Clinician payment information can be found here: https://www.cms.gov/EHRIncentivePrograms 

2018 EHR Eligible Professional Payment Adjustment

The EHR Incentive Program downward payment adjustment began to apply to Medicare Physician Fee Schedule payments for covered professional services furnished January 1, 2015 through December 31, 2015. The payment adjustment amount is established by statute for a specific calendar year and continues through the end of CY 2018. The table below illustrates the application of the reduced amount.

Payment Adjustment Background

• The program started in 2011, and incentive payments continued under Medicare through 2016. Clinicians could have received EHR incentive payments under Medicare for up to 5 consecutive years throughout the duration of the program.
• The last year to begin participation and receive an incentive payment under Medicare was 2014. To receive the maximum total amount of incentive payments, clinicians must have started participation by 2012. Clinicians who demonstrated meaningful use of certified EHR technology could have received up to $43,720 under Medicare over 5 consecutive years.
• To qualify for incentive payments under Medicare, clinicians must have successfully demonstrated meaningful use for an applicable EHR reporting period for each payment year of the program.
• From 2015 through 2018, clinicians who do not successfully demonstrate meaningful use will be subject to a downward adjustment to Medicare physician fee schedule payments for covered professional services.Clinicians who are not meaningful EHR users –  
• Clinicians who received the e-prescribing downward adjustment for not being a successful electronic subscriber in 2014 and were subject to the EHR downward adjustment in the Medicare EHR Incentive Program in 2015 received an additional 1.0% EHR downward adjustment for 2015 only. This resulted in those clinicians receiving 98% of the amount that would otherwise apply to such services during 2015.

2018 EHR Exceptions Process for clinicians

Clinicians may apply for significant hardship exceptions to avoid the payment adjustments described above. Such exceptions may be granted for certain categories of clinicians, or on a case-by-case basis, and only if CMS determines that compliance with the requirement for a clinicianto be a meaningful EHR user would result in a significant hardship.

Information on how to apply for a hardship exception is posted on the CMS EHR Incentive Programs website (https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/PaymentAdj_Hardship.html).

Applications must be submitted no later than July 1^st of the year before the applicable payment adjustment year. For example, for the 2018 payment adjustment, a clinicianmust have submitted a hardship exception application by July 1^st, 2017.

Applicable hardship exceptions categories for clinicians:

• For the 2018 payment adjustment only, a clinician who has not successfully demonstrated meaningful use in a prior year, intends to attest to meaningful use for an EHR reporting period in 2017 by October 1, 2017 to avoid the 2018 downward payment adjustment, and intends to transition to the Merit–Based Incentive Payment System (MIPS) and report on measures specified for the advancing care information performance category under the MIPS in 2017. Applications requesting this exception must have been submitted no later than October 1, 2017.
• Infrastructure – A clinician must demonstrate that they are in an area without sufficient internet access or face insurmountable barriers to obtaining infrastructure (e.g., lack of broadband or high cost build out for internet for facility).
• New clinicians – Newly practicing clinicians who would not have had time to become meaningful EHR users can apply for a time-limited exception to payment adjustments. For example, clinicians who began practice in 2016 would receive an exception to the payment adjustment in 2016 and 2017, but would have had to begin demonstrating meaningful use in 2017 to avoid the payment adjustment in 2018.
• Extreme and Uncontrollable Circumstances – Examples may include a natural disaster or other unforeseeable barriers such as the issues some clinicians faced with implementing 2014 edition Certified EHR Technology or switching Certified EHR Technology products during the year.
• For clinicians practicing in multiple locations: Lack of control over the availability of Certified EHR Technology at their practice location.
• By Specialist– a clinician must demonstrate that they meet the following criteria:
  • Lack of face-to-face or telemedicine interaction with patients
  • Lack of follow-up need with patients

Anesthesiologists, pathologists, and radiologists may receive hardship exceptions without applying based on their primary specialty as listed in the Provider Enrollment Chain and Ownership System (PECOS) six months prior to the first day of the year in which the payment adjustment would otherwise apply.

In addition, a clinician will be exempted from the application of the downward payment adjustment for 2018 if compliance with the requirement for being a meaningful EHR user is not possible because the certified EHR technology used by the clinician has been decertified under ONC's Health IT Certification Program. Applications requesting this exception must have been submitted no later than October 1, 2017.                                                                                                                 

2018 EHR Incentive Program and Payment Adjustments

Clinicians must demonstrate meaningful use every year in order to avoid Medicare downward payment adjustments in the years identified above. For example, a clinician that demonstrated meaningful use for the first time in 2013 would have avoided the payment adjustment in 2015, but would have had to demonstrate meaningful use again in 2016 in order to avoid the payment adjustment in 2018. It is important to note that 2018 is the last year of downward payment adjustments for clinicians in the Medicare EHR Incentive Program.

There are approximately 180,000 clinicians subject to a downward payment adjustment in 2018 under Medicare for failing to demonstrate meaningful use.

For more information on the Medicare and Medicaid EHR Incentive Program please visit:

https://www.cms.gov/EHRIncentivePrograms

###