New Option for Calculating Patient Volume Threshold Using Group Proxy Methodology

Group Proxy includes ALL providers within the group whose encounters contributed to the patient volume during the 90-day reporting period selected by the clinic/practice (including providers not eligible for the Medicaid EHR Incentive Payment Program). Provider organizations should determine the best scenario for maximizing the number of Eligible Professionals who will receive incentives and define logical groups of Eligible Professionals across the entire organization, considering both provider type and practice site.

Note: A group is defined as two or more Eligible Professionals who practice at the same site or within a physician foundation with a unique NPI or Tax ID

If employed by a hospital/organization* that uses the same NPI and Tax ID for all clinics, Eligible Professionals who elect to use the Group Proxy Methodology have the following options to break down their encounter or enrollee data:

  • Physician Foundations that have separate NPIs or Tax IDs
  • Ambulatory Clinic and practice site location (sites that provide both inpatient and outpatient services) or
  • Stand-Alone Outpatient Facility (no inpatient services provided) that houses multiple clinics that are owned and operated by the same health care organization

​Note: To qualify for the Medicaid EHR Incentive Payment Program, hospital-employed Eligible Professionals must practice less than 90 percent of their time in an Inpatient (POS 21) or Emergency Room (POS 23) setting.

Regardless of the Group Proxy Methodology option chosen, before completing the attestation process, all hospitals/organizations are required to submit to MeHI for prior approval:

  1. a group roster; and 
  2. supporting documentation for total paid claims or enrollee data; e.g., numerator and denominator) for the selected reporting period

The Group Proxy Methodology may only be used when all the following apply:

  1. The group’s patient volume is appropriate to use for the Eligible Professional because 1) the provider was a part of the practice at any time in the prior calendar year, and served at least one Medicaid* patient; OR 2) the provider is new to the practice and is currently seeing Medicaid* patients.
    Note: “Medicaid patient” is defined as a patient who was enrolled with Medicaid on the date of service or for whom Medicaid paid at least part of the service
  2. Provider organizations are prepared to demonstrate how patient volume was determined. There must be an auditable data source to support the group’s patient volume data, including a record of the processes used to record data. The organization is required to develop a query that identifies the total number of enrollees or paid encounters.  Please note that Federally Qualified Community Health Centers can include Medicaid and needy individual paid encounters or enrollees.
  3. All Eligible Professionals in the group must use the same patient volume calculation method for the payment year.
  4. The group uses the entire practice or clinic’s patient enrollee or paid encounter volume, including non-eligible providers (this includes ancillary providers); the practice cannot limit patient volume in any way.
  5. If an Eligible Professional works both inside and outside of the group, the patient volume threshold calculation should include only those encounters associated with the group, and not the Eligible Professional’s outside encounters.
  6. An organization must have an approved resident proposal on file with MeHI in order to include their residents. Also, organizations are required to identify the resident’s practice location, ambulatory clinic or foundation and supervising MD.