No one said that achieving meaningful use of electronic health records (EHR) would be easy. But few believed it would be as difficult and complicated as it’s become. Recognizing this, the Centers for Medicare & Medicaid Services (CMS) has established a hardship exception. It’s not an “out,” but it does allow providers more time to meet the meaningful use requirements.

Payment adjustments to Medicare-eligible professionals (EPs) began on January 1, 2015. These adjustments are based on the 2013 reporting year. EPs may be exempt from payment adjustments for failure to meet meaningful use requirements by demonstrating a significant hardship. To be considered for an exception, an EP must complete and submit a hardship exception application, along with proof of the hardship.

If the application is approved, the hardship exception is valid for one payment year only or one stage of the entire five-stage meaningful use program. A new application must be submitted if the hardship continues for the following payment year. In no case may a provider be granted an exception for more than 5 years.

Do you qualify?
EPs who first demonstrated meaningful use in 2011 or 2012 must have demonstrated meaningful use for a full year in 2013 to avoid the 2015 payment adjustments. EPs who first demonstrated meaningful use in 2013 (based on a 90-day reporting period) will also avoid payment adjustments in 2015. EPs must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years.

EPs can use the CMS-provided Hardship Exception Tool to determine if they should apply for a hardship exception. Although it is too late to apply for a hardship exception for 2015 (the application deadline was July 1, 2014), CMS has not yet determined the hardship application deadline for 2016. The Hardship Exception Tool can be found on the CMS website.

Automatic exceptions
Some providers will automatically be granted a hardship exception. CMS will use Medicare data on these providers to determine whether they qualify. The following providers do not need to submit a hardship application:

• new providers to the profession in their first year of practice
• hospital-based EPs (a provider is considered hospital-based if he or she provides more than 90 percent of covered professional services in either an inpatient or emergency department of a hospital)
• EPs with 90 percent of their claims in an inpatient or emergency department of a hospital and certain observation services
• EPs with certain PECOS (Provider Enrollment, Chain and Ownership System) specialties (anesthesiology, pathology, diagnostic radiology, nuclear medicine, and interventional radiology) 6 months prior to the first day of the payment adjustments. EPs should verify that their PECOS specialty is up-to-date.

Qualifying hardships
EPs can apply for hardship exceptions in the following categories:

• Infrastructure—EPs must demonstrate that they are in an area without sufficient Internet access or face insurmountable barriers to obtaining infrastructure (lack of broadband).
• New EPs—Newly practicing EPs who would not have had time to become meaningful users can apply for a 2-year limited exception to payment adjustments. Thus, EPs who begin practice in calendar year 2015 would receive an exception to the penalties in 2015 and 2016, but would have to begin demonstrating meaningful use in calendar year 2016 to avoid payment adjustments in 2017.
• Unforeseen circumstances—Examples may include a natural disaster or other unforeseeable barrier.
• 2014 EHR vendor issues—The EP’s EHR vendor was unable to obtain 2014 certification or the EP was unable to implement meaningful use due to 2014 EHR certification delays.
• Patient interaction—The EP has little or no face-to-face or telemedicine interaction with patients; follow-up with patients is not necessary.
• Practice at multiple locations—The EP has no control over availability of certified EHR technology for more than 50 percent of patient encounters.

Payment Adjustment Plan
Table 1 illustrates the potential application of payment adjustments to covered professional services for a Medicare EP who is not a meaningful user beginning in 2014. Because mandated payment adjustments began on the first day of the 2015 calendar year, CMS applied a prospective determination for payment adjustments. Therefore, Medicare EPs had to demonstrate meaningful use prior to the 2015 calendar year to avoid the adjustments.

EPs who first demonstrated meaningful use in 2011 or 2012 had to demonstrate meaningful use for a full year in 2013 to avoid payment adjustments in 2015. They must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years. Table 1 also illustrates the timeline to avoid payment adjustments for these EPs.

But wait … there’s more. Final rules for Stages 3, 4, and 5 have yet to be released. Expect this program to become increasingly complex as it continues into the future.

Howard Mevis is the director of the department of electronic media, evaluation programs, course operations, and practice management. He can be reached at mevis@aaos.org

Additional Information:
Hardship Exception Tool [PDF]

Meaningful Use Toolkit [PDF]

Meaningful Use: Preparing for an Audit

Health Information Technology (HIT) - AAOS

Electronic Health Records Position Statement AAOS