Watchdog call for EHR bonus audits meets resistance

Washington Putting additional hurdles in the way of incentives for meaningful use of electronic health records could impede adoption of health information technology, officials said following the release of an investigation critical of integrity safeguards in the incentive program.

The Centers for Medicare & Medicaid Services has paid roughly $4 billion to about 82,500 professionals and 1,500 hospitals for adopting and using certified EHR technology, but the incentives lack a thorough accounting that ensures pay goes to those actually achieving meaningful use of the paperless records, according to the Nov. 28 report. The Dept. of Health and Human Services Office of Inspector General conducted an early assessment of CMS oversight of the EHR incentives and criticized the agency for failing to confirm the information reported by physicians and facilities before sending out bonus payments.

“Although CMS is not required to verify the accuracy of this information prior to payment, doing so would strengthen its oversight of the anticipated $6.6 billion in incentive payments,” the OIG report said. “Verifying self-reported information prior to payment could also reduce the need to identify and recover erroneous payments after they are made.”

Physicians can earn up to $44,000 from Medicare or up to $63,750 from Medicaid by reporting that they met certain minimum objectives signifying meaningful use of EHRs. The agency is paying out annual lump-sum bonuses for meaningful use, but in 2015, federal law requires Medicare to start lowering rates paid to eligible physicians who do not use EHRs.

Health professionals receive incentive payments after attesting that they met meaningful use requirements. The OIG wants CMS to certify the information reported by physicians in those attestations before the checks go out the door. The Inspector General recommended that CMS review supporting documentation from selected professionals and hospitals before payment.

But the agency overseeing the EHR program opposed the suggestion for enhanced prepayment reviews of meaningful use claims, acting CMS Administrator Marilyn Tavenner indicated in a memo to the OIG. CMS already has implemented certain prepayment verification protocols. For instance, it validates all EHR system certification numbers reported by physicians and hospitals.

“It would be particularly difficult to implement for providers after their first year of participation because the reporting period is an entire year, and all [meaningful use] attestations are received in a two-month period during which CMS would have to review supporting documentation,” Tavenner said. “To change this process and implement prepayment audits could significantly delay payments to providers.”

The American Medical Association also disagreed with the OIG recommendation for prepayment audits. However, it concurred with other suggestions in the report to CMS and the HHS Office of the National Coordinator for Health Information Technology, which defines technical components of the incentive program.

“We oppose prepay audits in the meaningful use program, as they would impose additional burdens on physicians who already face separate program requirements for multiple Medicare health IT and quality programs, but the AMA supports the OIG’s other recommendations,” said Steven J. Stack, MD, chair of the AMA Board of Trustees. “We agree that CMS should issue clear guidance about the types of documentation physicians must maintain to support their compliance with the meaningful use program. We also support the recommendation that ONC improve the certification process for EHR technology and require certified EHR technology to produce compliant and accurate reporting documents.”

Postpay audits could snag physicians

The OIG could not review prepayment audits by CMS because the agency does not conduct them. However, CMS has conducted a number of postpayment reviews since June on health professionals who already had received meaningful use bonuses. The OIG anticipates that it will analyze those postpayment audits at a later date.

CMS contracted with the Garden City, N.Y., firm Figliozzi & Co. to conduct these audits. Peter Figliozzi, the firm’s managing partner, confirmed that his company actively is auditing physicians and hospitals for their meaningful use attestations. He declined to answer further questions about the audits and referred queries to CMS.

“Protecting taxpayer dollars is our top priority, and we have implemented aggressive procedures to hold providers accountable,” a CMS spokesman said. “Making a false claim is a serious offense with serious consequences, and we believe the overwhelming majority of doctors and hospitals take seriously their responsibility to honestly report their performance.”

CMS has taken steps to ensure physicians reporting meaningful use are using certified technology, said John Hellow, a partner at Hooper, Lundy & Bookman in Los Angeles. For instance, the agency uses vendor lists of products sold to practices and reviews attestation statements to ensure the information matches those lists. Hellow’s firm also has represented hospitals to identify inconsistencies in EHR reporting, and he knows of cases where meaningful use overpayments were returned to Medicare.

Still, any amounts recovered by Medicare from entities that did not meet program requirements do not compare to larger amounts recovered by federal anti-fraud activities, Hellow said. To date, there is little evidence showing mass amounts of fraud involving EHR bonuses, he said, adding that whether postpayment audits are stepped up or there is a move toward enhanced reviews during the prepayment stage will depend on the prevalence of fraud uncovered by Figliozzi.

“If they find a lot of doctors who reported to be certified users when they did not use certified technology, then they might have them send proof they acquired certified EHR technology,” Hellow said. “I wouldn’t worry about that until I see the base year audits. The OIG has a job, and they will always recommend putting in the earliest hurdle to prevent fraud.”

Adding barriers to incentives would defeat the purpose of the meaningful use incentive program, Hellow added. Congress sought to encourage hospitals and physician practices to abandon paper for electronic records in the 2009 economic stimulus law. The program’s design was to encourage the quick adoption of EHRs by professionals who did not use them.

“Prepayment audits would interfere with that, and doctors would pull back,” he said.

Other prepay reviews sought

Eliminating an estimated $60 billion in annual fraud, waste and abuse in Medicare has continued to be a focus of federal lawmakers. Government agencies have made strides to improve the way they catch criminals who have stolen federal dollars, but mechanisms to stop fraudulent payments from being made in the first place have not been implemented, said Rep. Joe Pitts (R, Pa.), the House Energy and Commerce health subcommittee chair, during a Nov. 28 hearing.

CMS has made a number of changes to its physician enrollment process to try to weed out fraudulent participants, but it could strengthen enrollment criteria by requiring disclosures of any payment suspensions from other federal programs, said Kathleen King, health care director at the Government Accountability Office. CMS also could improve its fraud prevention system by integrating it throughout the program.

“This level of integration would allow for the prevention of payments until suspect claims can be investigated and determined to be valid,” she said.