In 2024, participating practices completed over $11 million in activities eligible for the Equality Care Incentive Program (ECIP). That is real money tied to real clinical work — wellness visits, post-discharge follow-ups, chronic condition management, and preventive screenings paid out quarterly, not at the end of a performance year. But for every activity that earned, we see another that was completed in the exam room and never counted. The referral did not include evidence. The chronic care visit happened a week outside the window. The sick visit was not converted. The ECIP Eligibility Reference Guide (ERG) lays out exactly what counts — and what does not. Here is where most practices hit their earnings ceiling, pillar by pillar, and what to do about it.
Adult and Child Wellness Visits: Over 30% of Activities Paid
The earnings leak.
Wellness visits accounted for over 30% of all ECIP activity-based payments in 2024. The most common way practices leave money here is the missed Sick-to-Well Visit conversion. A child comes in for an ear infection. The provider addresses the acute concern, asks about immunizations, checks the growth chart — but the visit is billed as sick-only. That wellness activity never gets captured.
The ERG rule most practices miss.
The ERG requires a minimum of 14 calendar days between each well-care visit date of service for W15 and W30 measures. If visits are scheduled too close together, the second one will not count. Additionally, Sick-to-Well conversion using Modifier 25 is accepted where payer reimbursement policies allow — but only when the preventive components are fully documented as a distinct encounter.
The fix.
CareEmpower®’s Chart Prep Tool flags Sick-to-Well conversion opportunities before every scheduled visit. When the front desk pulls up tomorrow’s schedule, the tool surfaces which patients have open wellness activities — so the care team knows a sick visit can pull double duty before the patient walks in the door. For W15 and W30 tracking, CareEmpower prompts each visit in the series independently and shows the date of the last completed visit, making it easy to confirm the 14-day spacing requirement is met.
Prevention & Screenings: The Pillar Where Referrals Alone Do Not Count
The earnings leak.
Prevention and Screenings is the pillar that catches practices off guard. A provider identifies an open cervical cancer screening opportunity in CareEmpower, refers the patient to an OB/GYN or imaging center, documents the referral — and assumes the activity will close. It does not. The referral was made, but the evidence of closure never came back.
The ERG rule most practices miss.
This one is worth quoting directly from the ERG: “To earn an activity-based payment for Prevention and Screenings, Equality Health must receive evidence of closure from Health Plans; an opportunity will not be eligible for closure simply by referring a patient to another care provider.” That means the practice needs to confirm that the screening was completed and that the corresponding visit and lab codes appear in payer files. For cervical cancer screening specifically, if the practice has an open CareEmpower opportunity, it can offer HPV self-collection in-office or refer to an OB/GYN — but credit only arrives when the payer data shows the screening happened. Practices must also document in CareEmpower both the date the screening was performed and the result of the finding.
The fix.
Close the loop on every referral. When a screening is ordered, flag it for follow-up in your practice workflow. If results do not come back within a reasonable window, your Practice Performance Advisor (PPA) can help you build a tracking process to chase outstanding results before the measurement period closes. For cervical cancer screening, consider offering HPV self-collection in-office when appropriate — it removes the referral dependency entirely and keeps the evidence within your practice’s documentation.
One additional note: screening measures vary by market. CIS-3 applies in Arizona, Louisiana, and Virginia. CIS-10 applies in Texas, Tennessee, and Virginia. Your PAM can walk you through which measures are active for your practice.
Transitions of Care: Over 13% of Activities Paid
The earnings leak.
Transitions of Care is the most time-sensitive pillar — and the one where the window closes fastest. The ADT-IP activity requires a complete office visit within seven calendar days of an eligible hospital discharge. That visit must include a review of discharge instructions and medications, and address social needs or referrals. Seven days goes fast, especially when the practice does not learn about the discharge until the window is already shrinking.
The ERG rule most practices miss.
For follow-up after mental health hospitalization (FUH7 or FUH30, depending on the payer), the follow-up date of service cannot be the same day as the discharge. It sounds like a minor detail, but a same-day visit that would otherwise qualify gets disqualified on timing alone. For Medicare patients, the ADT-IP discharge also triggers a Medication Reconciliation Post-discharge (MRP) requirement — CPT II code 1111F must be documented. Miss the code, miss the payment.
The fix.
CareEmpower ingests admit/discharge/transfer (ADT) data from health information exchanges in real time. When a member is discharged, they appear on the practice’s prioritized worklist with a clear flag and a due date. The practice does not have to wait for a claims lag or a fax from the hospital. For postpartum care (PPC2), the window is wider — one visit between 7 and 84 days post-delivery — but the same principle applies: if CareEmpower flags it, schedule it before the window closes.
Chronic Care Management: Over 41% of Activities Paid
The earnings leak.
This is the largest ECIP pillar by a significant margin, and it is also the one with the most misunderstood eligibility rules. Practices often assume that any member with an eligible chronic condition — asthma, COPD, cardiovascular disease, diabetes, pre-diabetes, kidney disease, obesity, or a behavioral health condition including substance use disorder — automatically qualifies for a Chronic Care Management activity. They do not.
The ERG rule most practices miss.
The ERG is explicit: “Presence of any one condition will not automatically correlate to a Chronic Care Management care gap. Our algorithm will identify eligible condition(s) combined with identified changes to medications, hospitalizations and ER visits, etc.” In other words, Chronic Care Management activities are triggered by an eligible condition plus an adverse clinical event — frequent ED visits, uncontrolled labs, medication non-adherence, or a hospitalization. The activity opens monthly, not annually, for members who meet both criteria. And critically, the visit must occur during the calendar month in which the opportunity opens. A visit in the following month, even if clinically appropriate, will not close the prior month’s activity.
The fix.
Check CareEmpower’s worklist daily — not weekly, not when you have time. Because Chronic Care Management opportunities open and close on a monthly cycle, a member who appears on Monday’s worklist needs to be seen before the end of that calendar month. The good news is that the visit itself is straightforward: standard evaluation and management codes only, no additional forms or uploads required. Your PPA can help build a scheduling rhythm that pulls members with complex care needs into the calendar proactively rather than chasing them in the last week of the month.
The Ceiling Is Not the Care. It Is the Capture.
In most practices we work with, the clinical work behind ECIP is already happening. Providers are managing chronic conditions, completing wellness visits, following up after discharges, and ordering screenings. The earnings ceiling is not a clinical problem — it is a capture problem. An activity completed in the exam room that does not meet the ERG’s timing, documentation, or evidence requirements is an activity that does not earn.
CareEmpower surfaces the opportunities. Your PPA helps build the workflows. Your Provider Account Manager (PAM) tracks the progress quarterly and keeps your earnings visible. The ERG tells you exactly what counts. When you put those pieces together, the gap between what your practice earns and what it could earn starts to close — quarter by quarter, pillar by pillar.
