Eligible Professionals - Attestation

Per federal requirements, all Medicaid Promoting Interoperability incentives must be issued by December 31, 2021. This requirement necessitates changes to the typical reporting period and attestation timelines available to Eligible Professionals in Program Years 2020 and 2021. See the Attestation Dates and EHR Reporting Period for Meaningful Use sections below for important information regarding these timelines.

 

Overview

To receive a Wisconsin Medicaid Promoting Interoperability Program payment, Eligible Professionals must attest to the adoption, implementation, upgrade or Meaningful Use of certified electronic health record (EHR) technology (CEHRT). Meaningful Use is the standard by which providers demonstrate the use of CEHRT in ways that can positively affect the care of patients. To meet meaningful use requirements and receive an incentive payment, providers must meet a set number of objectives and measures established by the Centers for Medicare and Medicaid Services (CMS) for the Medicaid Promoting Interoperability Program. More detailed information is provided below.

Attestation Dates

Program Year 2020: Eligible Professionals may submit a Program Year 2020 attestation through the ForwardHealth Portal, between October 1, 2020, and January 31, 2021.

Program Year 2021: Eligible Professionals may submit a Program Year 2021 attestation through the ForwardHealth Portal, between April 1, 2021, and August 1, 2021.

Certified EHR Technology

Before an Eligible Professional can attest to meeting Promoting Interoperability Program requirements, he or she must acquire or have access to CEHRT. In Program Year 2019 and subsequent program years, all Eligible Professionals are required to use technology certified to the 2015 Edition.

For more information on CEHRT, including how to obtain the CMS EHR Certification ID used during registration and the Wisconsin incentive application process, please refer to the Certified Health IT Product List.

Adopt, Implement, Upgrade

Eligible Professionals participating in their first year did not have to attest to Meaningful Use criteria; rather, they could demonstrate that they adopted, implemented, or upgraded CEHRT. Beginning in Program Year 2017, Eligible Professionals may no longer attest to the adopt, implement or upgrade (AIU) phase.

Meaningful Use

Participation Timeline

The last year for an Eligible Professional to initiate participation in the Medicaid Promoting Interoperability Program is 2016. Calendar Year 2021 is the last year a participant may receive an incentive payment.

The criteria for Meaningful Use are staged in three steps over the course of the program:

  • Stage 1 sets the baseline for electronic data capture and information sharing.

  • Stage 2 and Modified Stage 2 advance clinical processes.
    CMS established a modified set of criteria for attestation in Program Years 2015 through 2018, known as Modified Stage 2. Modified Stage 2 replaced the core and menu structure of Stages 1 and 2 with a single set of objectives and measures, and establishes several other changes to the program.

  • Stage 3 improves outcomes.

In Program Year 2019 and beyond, Eligible Professionals must attest to Stage 3 of Meaningful Use.

EHR Reporting Period for Meaningful Use

Program Year 2020: In Program Year 2020, the EHR reporting period for Eligible Professionals is any continuous 90 days between January 1, 2020, and December 31, 2020.

Program Year 2021: In Program Year 2021, the EHR reporting period for Eligible Professionals is any continuous 90 days between January 1, 2021, and July 31, 2021.

Note: Eligible Professionals are not required to attest in consecutive years and may attest to the AIU phase and then a 90-day EHR reporting period in a subsequent year of participation.

Stage 3 Meaningful Use

The requirements for Stage 3 contain eight objectives for Eligible Professionals, including one consolidated public health reporting objective.

Eligible Professionals will attest to all eight objectives by either meeting the measure(s) or satisfying an exclusion, if applicable. Eligible Professionals may choose to satisfy an exclusion, rather than meet the measure, when the measure is not applicable to them and they meet the exclusion criteria.

Stage 3 includes flexibility within certain objectives to allow Eligible Professionals to choose the measures most relevant to their patient population or practice. The Stage 3 objectives with flexible measure options include:

  • Coordination of Care through Patient Engagement – Eligible Professionals must attest to all three measures and meet the threshold for two measures for this objective. If the Eligible Professional meets the criteria for exclusion from one measure, the remaining two measure thresholds must be met. If the Eligible Professional meets the exclusion criteria for two measures, the threshold for the one remaining measure must be met. If the Eligible Professional meets the exclusion criteria for all three measures, they may claim all three exclusions and satisfy the objective.
  • Health Information Exchange – Eligible Professionals must attest to all three measures and must meet the threshold for two measures for this objective. If the Eligible Professional meets the criteria for exclusion from one measure, the remaining two measure thresholds must be met. If the Eligible Professional meets the exclusion criteria for two measures, the threshold for the one remaining measure must be met. If the Eligible Professional meets the exclusion criteria for all three measures, they may claim all three exclusions and satisfy the objective.
  • Public Health Reporting – Eligible Professionals must meet two measures for this objective. If the Eligible Professional cannot satisfy at least two measures, they may take exclusions from all remaining measures they cannot meet, in order to satisfy this objective.

For more information on the Eligible Professional Stage 3 requirements for Program Year 2020, review the Eligible Professional Meaningful Use Specification Sheets. Check the CMS website for a link to the Program Year 2021 Stage 3 Meaningful Use Specification Sheets.

Process for Reporting Public Health Objectives

All Eligible Professionals, regardless of their stage of Meaningful Use, are required to register with the Wisconsin Department of Health Services (DHS), Division of Public Health (DPH), to initiate an onboarding process for the public health report objective. For current registration information, Eligible Professionals should refer to the Public Health Meaningful Use website.

Electronic Clinical Quality Measures (eCQMs)

In addition to meeting the Meaningful Use measures, Eligible Professionals are also required to report on eCQMs. Although eCQMs are reported separately from Meaningful Use measures, all Eligible Professionals are still required to report eCQMs in order to demonstrate Meaningful Use.

All Eligible Professionals, regardless of their stage of Meaningful Use, are required to report on six of the available eCQMs. Of the six, one must be an "outcome" measure. If no outcome measures are relevant to the provider’s scope of practice, then the provider must report on one "high-priority" eCQM. If no outcome or high-priority eCQMs are relevant to the Eligible Professional’s scope of practice, the Eligible Professional must report on any six eCQMs. See the Wisconsin High-Priority Electronic Clinical Quality Measures (P-012315) document for more information on the available outcome and high-priority eCQMs.

Zero is an acceptable value for the eCQM denominator, numerator, and exclusion fields and will not prevent you from demonstrating Meaningful Use or receiving an incentive payment. Eligible Professionals can meet the eCQM requirements even if one or more eCQMs have “0” in the denominator, provided that this value was produced by CEHRT.

See the CMS Clinical Quality Measure Basics page on the CMS website to learn more about reporting eCQMs. For a complete listing of available eCQMs, refer to the Electronic Clinical Quality Improvement (eCQI) Resource Center.

Electronic Clinical Quality Measure (eCQM) Reporting Periods

Program Year 2020: The eCQM reporting period for all Eligible Professionals is any continuous 90-day period between January 1, 2020, and December 31, 2020. 

Program Year 2021: The eCQM reporting period for all Eligible Professionals is any continuous 90-day period between January 1, 2021, and July 31, 2021. 

Note: Although the EHR reporting period and the eCQM reporting period are both 90 days, Eligible Professionals are allowed to choose different 90-day periods.

Attestation Supporting Documentation

All information is subject to audit at any time and must be maintained by Eligible Professionals for a period of six years. If selected for an audit, the applicant must be able to supply supporting documentation. A failed audit may result in a recoupment of incentive payments. Refer to the ForwardHealth Online Handbook for a table that contains examples of supporting documentation an Eligible Professional would be expected to provide if selected for an audit.

Office of the National Coordinator for Health Information Technology Questions

CMS requires Eligible Professionals to attest to Objective 0, which contains a series of questions about cooperation with the following policies:

  • Demonstration of supporting information exchange and prevention of information blocking.
  • Demonstration of good faith with a request relating to Office of the National Coordinator for Health Information Technology (ONC) direct review of CEHRT.

The Objective 0 Tip sheet was developed to help you understand this requirement prior to attestation.

Last Revised: July 27, 2020