CMS, in a switch, starts prepayment meaningful use audits

Incentive checks could be delayed if a physician's electronic submission is flagged for possible problems, or chosen at random for review.

By — Posted April 15, 2013

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Some physicians waiting for their meaningful use incentive checks to arrive in the mail may be surprised when, instead, they get a letter stating they are being audited.

In March, the Centers for Medicare & Medicaid Services started conducting prepayment audits of physicians and other eligible professionals who have attested to meeting requirements of the meaningful use incentive program. The audits are in addition to postpayment audits the department began conducting in the summer of 2012.

The addition of prepayment audits comes after the Dept. of Health and Human Services' Office of the Inspector General published a report in November 2012 that criticized CMS for not doing enough to prevent improper payments. The report recommended that CMS conduct audits to verify information in the attestation documents before bonus checks are sent to those physicians.

“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 report stated. “Verifying self-reported information prior to payment could also reduce the need to identify and recover erroneous payments after they are made.”

The prepayment audits are similar in scope and size to postpayment audits, according to CMS. Each month, CMS will audit between 5% and 10% of the attestation documents it receives. The sampling will include documents that look suspicious or anomalous, as well as others chosen at random. Meanwhile, postpayment audits can be initiated at any time.

Focus of audits

James Wieland, a partner at the Baltimore-based law firm Ober|Kaler co-wrote an alert in the summer of 2012 after clients who received postpayment audit notices contacted his firm. He said the auditors, whether they work pre- or postpayment, generally are looking for three things from physicians:

Proof that the EHR system used to meet meaningful use requirements is certified. The Office of the National Coordinator for Health Information Technology maintains a list of certified systems on its website. The list can be annotated and sent to CMS to show which system the physician is using.

Documentation that core objectives were met. Fifteen core objectives must be met in stage 1 of the meaningful use initiative. EHR systems certified to meet meaningful use should be capable of generating reports proving compliance. The reports can be submitted electronically or printed out.

Documentation that menu objectives were met. Stage 1 requires physicians to choose five menu objectives from a list of 10. EHR-generated reports, including those used to support clinical quality measures, can show compliance.

Physicians must send documentation showing those EHR-generated reports were done appropriately, said Bill Fera, MD, principal of Ernst & Young's Health Care Advisory Services. For example, for percentage-based measures such as population of patients who received smoking cessation counseling, a report indicating the numerators and denominators used to calculate those percentages will be needed. The time span covered by the report also must be provided as well as evidence, such as patient lists, that the report was generated using data from the reporting facility's patient records.

The audits can be complete or partial, Dr. Fera said. Physicians can prevent their documents from being flagged by ensuring that calculations for percentage-based measures are correct, the supporting documents are aligned with the attested measure, and dates on the reports match those of the attestation period. He said suspicions also can be raised when documentation doesn't adhere to federal patient privacy standards.

“As a general rule, as physicians prepare to attest, they should do so with the expectation that they will be audited,” Dr. Fera said. “All logs and documentation should be stored for appropriate periods to support attestation on a rolling basis.”

CMS says on its website that physicians should keep all supporting documents for at least six years after attestation.

As of February, more than $2.3 billion had been paid out to more than 139,000 professionals, including physicians, for the Medicare program. More than $1.7 billion had been paid out to more than 79,000 professionals qualifying for the Medicaid program. Individual states are handling their own audits of the Medicaid program. CMS said it did not have information on how much money has been recovered through post- and prepayment audits.

Those selected for auditing will receive a letter from Figliozzi & Co., the Garden City, N.Y., firm CMS selected to perform the audits. Peter Figliozzi, the firm's managing partner, did not respond to a request for an interview.

The American Medical Association opposes prepayment audits. When the November 2012 OIG report was issued, AMA Board of Trustees Chair Steven J. Stack, MD, said the audits would “impose additional burdens on physicians who already face separate program requirements for multiple Medicare health IT and quality programs.”

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External links

“Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program,” Dept. of Health and Human Services' Office of the Inspector General, Nov. 28 [link]

Meaningful use program and data report, Centers for Medicare & Medicaid Services [link]

CMS on audits and EHR incentive program [link]

"Figloiozzi and Company Begin Meaningful Use Audits as CMS Designee," Health Law Alert Newsletter, Ober|Kaler, 2012 [link]

Certified Health IT Product List, Office of the National Coordinator for Health Information Technology [link]

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