1. Patient Volume Threshold (PVT) Massachusetts Medicaid EHR Incentive Program April 25, 2017
Today’s presenters:
Thomas Bennett, MeHI Technical Assistance Team
Elisabeth Renczkowski, Content Specialist

2. Disclaimer
This presentation was current at the time it was presented, published or uploaded onto the web. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage attendees to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.
Massachusetts eHealth Institute

3. Agenda Purpose of This Webinar
What is Medicaid Patient Volume Threshold (PVT)?
Selecting Your Strategy
PVT Prep Work
Refining Your Strategy
Methodology – Individual vs. Group Proxy
Defining and Selecting Your PVT Reporting Period
Defining an Encounter – Paid Claims vs. Enrollees
Calculating Your Patient Volume Threshold
Data Entry and Supporting Documentation
List of Data Elements Required
Reassessing Your Strategy
Common Issues
Questions

4. Purpose of This Webinar

5. Purpose of This Webinar
We want to help you:
save time by getting it right the first time
ensure the accuracy of your PVT data
At the end of this session, participants will understand:
the purpose of Medicaid PVT
options and strategies to optimize PVT while minimizing headaches
how to clean up and organize PVT data to eliminate errors
Cleaning up PVT data ahead of time may seem tedious and time-consuming, but it’s well-worth it in the long run and will ultimately SAVE TIME
Investing a little time now will ultimately save you time in the long run AND improve your confidence in your PVT numbers

6. What is Patient Volume Threshold (PVT)?

7. What is Medicaid Patient Volume Threshold (PVT)?
Medicaid patient volume determines if a provider is eligible for the Medicaid EHR Incentive Program
Ensures payments go only to providers who serve the target Medicaid population
Eligible Professionals (EPs) must bill at least 30% of their encounters to Medicaid over a consecutive 90-day period
Includes Fee-For-Service (FFS) and Managed Care Organization (MCO) – see the Medicaid 1115 Waiver Population Grid for a complete list
Board-certified pediatricians can meet a 20% threshold and receive a reduced incentive
EPs who work at a Federally Qualified Health Center (FQHC) can include both needy individuals and Medicaid patients to meet the 30% threshold
Patient volume eligibility must be demonstrated each year of participation; EPs must select a new reporting period every year
PVT does not require use of the CEHRT; organizations may use their billing system to extract their volume
Providers who do not satisfy the required 30% or 20%(Pedi) Medicaid threshold are not eligible to participate in the program and receive an incentive.
It’s extremely important to gather your data early and correctly to be certain the Provider is considered an eligible professional.
“serve Medicaid population” = a substantial % of their patients are Medicaid patients = a substantial % of their billing goes to Medicaid
People may associate the incentive program with MU or even use the term MU to refer to the program, but this ignores the importance of PVT
Medicaid PVT is just as important – in fact, providers who don’t meet 30% are ineligible, making CEHRT/MU a moot point

8. Selecting Your Strategy

9. Selecting Your Strategy
Conduct a self-assessment to decide the most advantageous method for the Eligible Professional to meet the required eligibility threshold
Learn about the options: The choices may seem confusing at first, but having a variety of options gives you a better chance of meeting the threshold
Individual vs. Group Proxy
Paid Claims vs. Enrollees
PVT reporting period options
Try the simplest way first
Are there more than two EPs attesting for an incentive?
Can the EP satisfy the 30% threshold using volume from one site?
Can you extract the volume from your billing system?
Pediatricians – try for 30% first
Learn about the options – that’s what we’re here to do today
Pediatricians – for simplicity we’ll talk about 30% throughout this presentation; 30% allows you to receive higher payment amount; NP issue (have to come in at 30% if doing Group Proxy and including NPs)

10. PVT Prep Work More than just data entry
Several things to consider before reporting in MAPIR:
How is the data extracted and compiled?
EHR, separate system, 3rd party biller, etc.
Assigning tasks –
Who is assigned to attest on behalf of the EP?
Acts as point of contact for MeHI staff
Completes MAPIR application
Uploads supporting documentation via MAPIR
Who verifies the accuracy of the patient volume detail?
Retrieves raw data and exports to Excel
Organizes, formats, and “cleans up” data
Confirms accurate numerator and denominator
Calculates PVT
Who will complete all those preparation steps?
Designee/preparer – person assigned to attest on behalf of the EP

11. Refining Your Strategy

12. Methodology: Individual vs. Group Proxy
To determine Medicaid Patient Volume eligibility, EPs may use either individual data or the Group Proxy Methodology.
Individual data: each EP uses only his/her own patient encounters to establish Medicaid PVT
Group Proxy Methodology: all providers in the practice (including those not eligible for the Medicaid EHR Incentive Program) aggregate their data to determine the group’s Medicaid PVT
A group is defined as two or more EPs practicing at the same site
Please see our Group Proxy Guide for more information

13. Methodology: Individual vs. Group Proxy
Once a method is selected, all attesting EPs must submit their applications using the same methodology
An organization cannot have some EPs who use individual data and others who use Group Proxy
Payment year and attestation phase (AIU vs. MU) do not impact Group Proxy – providers at different phases of the program can still attest as a group
Group Proxy Methodology usually involves less administrative burden and often allows more EPs to participate
Example: using individual data,
Dr. Green would not qualify;
aggregating the group’s data
allows all five EPs to participate
Dr. Green
25%
Dr. Brown
35%
Dr. Smith
Dr. Jones
Dr. Johnson
Group Total
33%
Advantages to Group Proxy – less administrative burden (single spreadsheet vs. one for each individual EP) and may allow more EPs to participate – for example, new EPs who just joined the practice or EPs who cannot achieve 30% on their own

14. Defining Reporting Periods
The PVT reporting period is any 90-day period from either the previous calendar year or the 12-month period leading up to attestation
Simplest approach: choose one timeframe and stick to it
Previous Calendar Year (CY) is always based on Program Year (PY), not the date of attestation
For example, for PY 2016 applications, the previous CY is 2015, regardless of when you attest (even if you attest in 2017)
Meaningful Use (MU) reporting period vs. PVT reporting period
Both are 90 consecutive days*
PVT reporting period is always from either the previous CY or the 12-month period leading up to attestation
MU reporting period is within the Program Year
*For Program Year 2016 and 2017, MU reporting period is 90 days; for Program Year 2018, MU reporting period is scheduled to be 365 days
Simplest approach: pick one timeframe and stick to it – don’t switch from year to year
Do not confuse the Meaningful Use reporting with the Patient Volume reporting period -- They can coincide, overlap, or be completely different

15. Selecting Your PVT Reporting Period
Keep in mind the PVT reporting period selected for the previous Program Year
Program Year
Attestation Date
Timeframe Selected
PVT Reporting Period Options
PVT Reporting Period Selected
PY 2015
March 31, 2016
12-month period preceding attestation
March 31, 2015 – March 30, 2016
April 1, 2015 –
June 29, 2015
PY 2016
May 1, 2017
Previous CY (2015)
January 1, 2015 – March 31, 2015
~~~~~~~~~~~~~~
June 30, 2015 – December 31, 2015
July 1, 2015 – September 28, 2015
Walk through each cell in the chart – demonstrate why April-June 2015 is out during PY2016

16. Selecting Your PVT Reporting Period, continued
Organizations that used individual methodology for the previous Program Year and intend to use Group Proxy for the current Program Year should pay extra attention to reporting period(s) selected previously
*In this case, the organization would have to select a PVT reporting period from the 12-month period leading up to attestation (May 1, 2016 – April 30, 2017)
Program Year
PVT Method
Attestation Date
Timeframe Selected
PVT Reporting Period Options
PVT Reporting Periods Selected
PY 2015
Individual
January 20, 2016
12-month period preceding attestation
January 20, 2015 – January 19, 2016
Dr. Jones:
March 1, 2015 –
May 29, 2015
~~~~~~~~~~~~~~
Dr. Smith:
August 1, 2015 – October 29, 2015
PY 2016
Group Proxy
May 1, 2017
Previous CY (2015)
None*
If individual methodology was used in the previous PY and Group Proxy is being used this year, the new PVT reporting period cannot coincide or overlap with any of the reporting periods selected for the previous PY
Again, the simplest approach is to choose one timeframe (either previous CY or 12-month period preceding attestation) and stick to it – it’s best not to switch from year to year

17. Selecting Your PVT Reporting Period – the “No-Fly Zone”
Month
Previous CY
12-month period preceding attestation
January 2015
Yes
February 2015
March 2015
April 2015
May 2015
June 2015
July 2015
August 2015
September 2015
October 2015
November 2015
December 2015
January 2016
No-Fly Zone
February 2016
March 2016
April 2016
May 2016
June 2016
July 2016
August 2016
September 2016
October 2016
November 2016
December 2016
January 2017
February 2017
March 2017
April 2017
May 2017
Assuming the EP attests on the deadline – May 31, 2017

18. Defining an Encounter – Paid Claims vs. Enrollees
To determine patient volume eligibility, EPs may use either Medicaid paid claims or Medicaid enrollees.
For EPs using paid claims, a patient encounter is defined as:
One service, per patient, per day, where Medicaid or a Medicaid Waiver Population paid for all or part of the service rendered, or paid for all or part of the individual’s premiums, co-payments, or cost-sharing
For EPs using the enrollee approach, a patient encounter is defined as:
One service rendered to a Medicaid or Medicaid 1115 Waiver enrolled patient, regardless of payment liability. This includes zero-pay encounters and denied claims (excluding denied claims due to the patient being ineligible on the date of service)
Please see the Medicaid 1115 Waiver Population Grid for a complete list of payers that are considered Medicaid
Paid claims is the best place to start – if you can meet PVT that way, it’s probably the simplest approach
If an EP is struggling to meet eligibility, you may include secondary and tertiary payers
Use the enrollee approach if the EP cannot meet the threshold based on paid claims.

19. Calculating Your Patient Volume Threshold

20. Calculating Your Medicaid Patient Volume Threshold
Medicaid Patient Encounters
(over any continuous 90-day period from the preceding calendar year or the 12 months preceding the provider’s attestation)
Total Patient Encounters
(over the same 90-day period)
Numerator: Medicaid Patient Encounters (FFS & MCO)
Denominator: Total Patient Encounters (All payers)

21. Calculating Your Medicaid Patient Volume Threshold
All encounters paid under the Children’s Health Insurance Program (CHIP) must be removed from the numerator
A percentage reduction (the CHIP factor) must be applied to the in-state numerator
The CHIP factor does not apply to out-of-state encounters
The CHIP factor varies depending on the PVT reporting period chosen and is based on the last day of the reporting period
Please see the CHIP Factor Grid on our website or contact us to determine the appropriate CHIP factor to apply to your numerator
Please note: Federally Qualified Health Centers (FQHCs) using the FQHC method to determine patient volume
do not need to apply the CHIP factor to their numerator
Example
CHIP factor
3.20%
Medicaid count (raw #)
300
CHIP applied
300 x .032 = 9.6
= 290.4
Medicaid count with CHIP
290
Alternately, you can multiply the raw Medicaid count (300) by 96.8% and save yourself a step

22. Data Entry and Supporting Documentation

23. Data Entry
When preparing patient volume data for MAPIR, ensure you have obtained all the data elements shown below:
Total In-State Medicaid Encounters
3,071
CHIP Reduction
-3.20%
-98
Reduced Total In-State Medicaid Encounters
2,973
Out-of-State Encounters 30
Reduced Total In-State plus Out-of-State Encounters
3,003
All Encounters from All Payers
9,706
% Medicaid
30.93%
Address out-of-state, CHIP, etc

24. Supporting Documentation
Eligible Professionals are required to submit PVT supporting documentation only upon request
Supporting documentation is requested when there is a variance of +/- 25% or greater between the PVT reported in the EP’s MAPIR application and the claims information extracted from the MassHealth Data Warehouse
All EPs should have their PVT supporting documentation available and retain all documentation for a minimum of 6 years post-attestation (in case of audit)
PVT documentation must be provided in a searchable format (i.e. Excel)
PVT supporting documentation must contain all required data elements

25. List of Data Elements Required

26. List of Data Elements Required
Include the following tabs/sheets and data elements (column headers) within your Excel spreadsheet:
Group Roster
Provider Name
Provider Type
NPI
Site
Group Name
Eligible to Participate in Medicaid
EHR Incentive Program – Y/N
Payer Key
Abbreviations
Full names
Medicaid – Y/N
All Payers (Denominator)
See Medicaid list 
Medicaid (Numerator)
Organization Name
Payee NPI
Location/Street Address
Unique Patient ID 1 (MRN)
Unique Patient ID 2 (DOB)
Date of Service
Primary Payer
Total Amount Paid
Claim Status (Enrollee method only)
Denial Reason (Enrollee method only)
Optional:
Rendering Provider Name
Rendering Provider NPI
Secondary Payer
Secondary Amount Paid
Tertiary Payer
Tertiary Amount Paid
Rationale behind why we need each data element (two pt. identifiers, etc.)
Remove any unnecessary columns/data – just complicates things

27. Reassessing Your Strategy

28. Reassessing Your Strategy: Preparing for Future Years
Keep in mind that a different PVT reporting period must be chosen for each Program Year
No-Fly Zone
Individual vs. Group Proxy issue
Reassess the most advantageous strategy for your practice
Maintain flexibility in your strategy – your patient population may change over the course of the year
Group vs. Individual – patient population may further vary by provider
Paid claims vs. Enrollees – enrollee allows you to include zero-pay and denied claims (as long as the reason for denial wasn’t ineligibility on the date of service)
Reporting period -- winter months may be better (flu shots, etc.)

29. Common Issues

30. Common Issues Difficulty extracting data from billing system
Data may not be in a format that’s conducive to determining Medicaid PVT
Excluding legitimate MassHealth payers from numerator
Issues identifying which payers are Medicaid (incomplete/inaccurate payer key)
Confusion over what constitutes a group for Group Proxy Methodology
Confusion around multiple sites or NPI/TIN combinations
Failing to include non-eligible providers who billed Medicaid during the reporting period
Three-month period vs. 90-day period
Most three-month periods have more than 90 days; Feb-April actually has less

31. Common Issues, continued
No-Fly Zone
90-day reporting period inadvertently falls outside 12-month period prior to attestation
Failing to remove duplicates, zero-paid claims, typos
Forgetting to apply the CHIP factor to the in-state numerator
Difficulty understanding which numbers correspond to the MAPIR fields
Supporting documentation must include 2 unique patient IDs (MRN and DOB)
Do not include PHI (first name, last name, social security number, etc.)

32. Questions
Questions?
General Q & A

33. Helpful Links MeHI MU Toolkit for Eligible Professionals
Medicaid 1115 Waiver Population Grid
Calculating Patient Volume
CHIP Factor Grid
Group Proxy Guide
COMING SOON
Updated PVT template spreadsheets
Guide to Removing Duplicates

34. Contact Us Thomas Bennett Client Services Relationship Manager
(508) , ext. 403
Brendan Gallagher
Client Services Relationship Manager
(508) , ext. 387
Al Wroblewski
Client Services Relationship Manager
(508) , ext. 603