EPs may use a clinic or group practice's patient volume as a proxy for their own under three conditions:
- The clinic or group practice's patient volume is appropriate as a patient volume methodology calculation for the EP (for example, if an EP only sees Medicare, commercial, or self-pay patients, this is not an appropriate calculation).
- There is an auditable data source to support the clinic's patient volume determination.
- The group EPs use the same methodology in each year (in other words, the clinic cannot have some providers using the same encounters in their patient volume when the same encounters were used in a group calculation).
The clinic or practice must use the entire practice's patient volume and not limit it in any way. EPs may attest to patient volume under the individual calculation or the group/clinic proxy in any participation year. Furthermore, if the EP works in both the clinic and outside the clinic (or within and outside a group practice), then the clinic/practice level determination includes only those encounters associated with the clinic/practice. The following is an example of how an EP would use the group patient volume method:
Dr. Sue, a physician practicing in pediatrics, works for ZZ Clinic, YY Clinic and individually. She alone has 19% patient volume therefore does not qualify for the program.
||Patient Volume %|
In the example above the pediatricians are part of a group and if you aggregate all of the Medicaid encounters and divide by the number of members you can arrive at the group volume of 123/400 = 31% Medicaid Patient Volume.
In this example, the group maximized their benefits. Each member of the group would attest to 123 Medicaid encounters and 400 for all encounters allowing all providers in the group to attest to 30% Medicaid volume. Notice in the example above, it is appropriate when using group encounter methodology to include all licensed professionals regardless of eligibility for the program. Dieticians are excluded from participation; however their encounters can be used in calculating group volume.
The practice maximized their benefits:
- The practice was allowed to use all the providers encounters
- Ms. Leigh is not eligible for the program, but her encounters are able to be used in the group methodology
- Dr. Tom could have attested as an individual and received the same year 1 incentive of $21,250 because he has more than 30% Medicaid Patient Volume.
- Dr. Sue would have not been eligible, but based on the calculation can attest and receive the full incentive of $21,250 in her first year of participation.
- If Dr. Bob would have attested individually he would have received $14,167 in their first year of the program. By utilizing the group methodology he can receive $21,250.
Dr. Pete is part of a large group practice with multiple locations consisting of providers that serve some Medicaid and providers that are enrolled but see no Medicaid patients. If the practice calculates the patient volume individually they have wildly varying results from 100% to 10% and would only be eligible for 70% of the clinics professionals. The practice includes professionals that are eligible for the program and some that are not. If the practice calculates the combined total of the group's patient volume based on Payee Tax ID and reaches 30% or more Medicaid utilization, then it is acceptable to use the entire practice's patient volume when attesting. This is the easiest method for HFS to validate.