Medicare or Medicaid EHR incentives? 6 things to consider

By Michelle McNickle
11:57 AM

Now more than ever, providers are exploring whether the Medicare or Medicaid reimbursement program is best to receive their EHR incentive payments. For many, both are an option, and according to Stephen Martinez, CEO at MTS Healthcare, it's imperative to understand the ins-and-outs of each in order to make an educated decision.

"We are often asked by providers whether they should apply for their EHR incentives through Medicare or Medicaid," he said. "While many providers are aware the financial incentives are for different amounts, the reporting and eligibility requirements are also very different. "

Martinez outlines six keys to EHR incentives and Medicare versus Medicaid.


1. Providers can apply for their first payment under "A/I/U." To receive the entire $63,750 from the Medicaid incentive program, said Martinez, providers can apply for their first payment under what's called A/I/U. "That is, they can either adopt – acquire or secure access to – an EHR system, implement or begin using, an EHR system, or upgrade their EHR system that's already in use," he said. "[Then] they're eligible to receive the first year payment of $21,250."

2. Providers who apply under the Medicaid program don't need to attest to MU during their first payment year. "They simply need to attest to A/I/U," said Martinez. In providers' second payment year, or the first year of demonstrating MU, providers have a 90-day meaningful use reporting period requirement, he continued. "Only beginning in their third payment year, or the second year of demonstrating MU, will providers have to attest for the full 12-month period, and for every year beyond in order to receive their payments," he said.

[See also: Medicare EHR incentive payments expected this week.]

3. Provider eligibility is based on the percentage of Medicaid patient volume seen at the practice.
If 30 percent of the patient volume is fee-for-service, or managed care Medicaid, Martinez said, providers can qualify for the Medicaid EHR incentive program. "Pediatricians can qualify with a lower minimum of 20 percent Medicaid patient volume and will be paid 66 percent of the Medicaid incentive. But [they could] be paid the full amount if their patient volume is 30 percent or greater."


1. Providers need to demonstrate 90 consecutive days of MU. To receive the entire $44,000 under the Medicare reimbursement program, said Martinez, providers need to demonstrate 90 consecutive days of MU beginning in 2011 or 2012. "Providers who were ready could have begun their 90-day reporting period for MU on January 1, 2011," he said. "If they had successfully passed the MU measures for 90 days, they could have applied on April 1, 2011 for their first financial incentive payment of $18,000."

[See also: Medicaid portal offers self-service.]

2. Providers also need to demonstrate MU for all of 2012 and for each subsequent year. Providers that demonstrated 90 days of MU in 2011 must also then demonstrate MU for the full 12- month period of 2012 and for each subsequent year in order to receive the maximum payments, said Martinez. "It is important to remember the 90-day reporting period must begin before October 1 to receive the financial incentive for that payment year," he said. After October 1, he continued, the 90-day reporting period would cross over into the following calendar year. "While providers would still receive $18,000 if they attest for MU in 2012, they would have to wait until 2013 to receive their second payment of $12,000."

3. Under FFS, the payment incentive amount is subject to an annual limit. Under fee-for-service Medicare, the payment incentive amount is subject to an annual limit, which is equal to 75 percent – up to $18,000 – of a provider’s Medicare allowable charges submitted no later than two months after the end of the calendar year, said Martinez. "This means, for 2011, the EHR incentive payment for a provider would be, subject to an annual limit, equal to 75 percent of the Medicare fee schedule allowable charges for CY 2011, based on claims for services performed from January 1, 2011 through December 31, 2011, and submitted no later than February 29, 2012," he said. Another way of looking at it? "For either 2011 or 2012, the incentive amount could not exceed $18,000, but it could be less based on charges submitted to Medicare."

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