Eligible Professionals — Eligibility Rules
Eligible Professionals can receive up to $63,750 over six years for Adopting, Implementing or Upgrading and demonstrating Meaningful Use of Certified EHR Technology (CEHRT). For more information on Eligible Professionals Program Requirements, please refer to the information below.
In order to qualify for the Wisconsin Medicaid EHR Incentive Program, a provider must meet the following requirements:
Medicaid Patient Volume
A Medicaid encounter is defined as services rendered on any one day to an individual enrolled in a Medicaid program, regardless of claim amount paid by Medicaid.
Eligible Professionals must meet at least 30% Medicaid patient volume (20% for Pediatricians) calculated at the individual provider or the group/clinic level.
Patient Volume Reporting Time
Eligible Professionals will need to calculate the Patient Volume 90-day eligibility period within one of the following time periods:
Note: Attestation date will be defined as the day when the application is electronically signed and submitted for the first time in the Program Year or the last day of the Program Year if applying during the grace period.
Global Billing Patient Encounter Clarification
When calculating patient volume, Eligible Professionals can count both individually billed and globally billed events as encounters as long as medical treatment and/or evaluation and management services are provided. Eligible Professionals should clearly document how globally billed encounters were derived in their patient volume calculations. Eligible Professionals are encouraged to upload this documentation as a part of their Wisconsin Medicaid EHR Incentive Program application in order to avoid delays in the review of the application.
Group/Clinic Patient Volume Option
If a provider is part of a practice or clinic, the patient volume may be calculated on a group level. This means the encounters for all practitioners (eligible and non-eligible providers) in a group practice are used to determine patient volume.
In order to use the group practice patient volume calculation, an Eligible Professional is required to have at least one encounter with an eligible member during the patient volume reporting period. This encounter does not need to be funded by Wisconsin Medicaid and does not need to occur at the current group practice. If the Eligible Professional is new to practicing medicine (e.g., a recent graduate of an appropriate training program), he or she does not need to provide proof of an encounter.
Needy Individuals Patient Volume Option
Providers that practice predominantly in an FQHC or RHC may use Needy Individuals in the patient volume calculation. Eligible Professionals practicing in an FQHC or RHC must have at least 30 percent (30%) patient volume attributable to Needy Individuals to be eligible for the program. Needy Individuals are defined in Section 1903(t)(3)(F) of the Social Security Act as individuals meeting any of the following three criteria:
Note: “Practice predominantly” is defined as providing 50% or more of services in an FQHC or RHC during a six month period in the previous calendar year or during the 12 months preceding the attestation date.
Since Wisconsin ForwardHealth includes both Medicaid and CHIP funding, Eligible Professionals do not have a way of knowing which funding streams cover their patients. The federal rule around the Medicaid EHR Incentive Program does not allow encounters paid by CHIP to be counted as part of the Medicaid patient volume, unless the patient is seen at a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC). To reduce this barrier, the Wisconsin Medicaid Agency annually calculates a Standard Deduction percentage of CHIP beneficiaries to be subtracted from the total Medicaid and BadgerCare+ beneficiary encounters. Eligible Professionals must use the Standard Deduction to remove their CHIP volume calculating Patient Volume.
For more information on the Patient Volume Methodology, please refer to Appendix A: Patient Volume (PDF, 257KB), in the State Medicaid Health Information Technology Plan (SMHP).
Last Revised: January 31, 2014