BEST PRACTICES FOR MEDICARE

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1 BEST PRACTICES FOR MEDICARE AND MEDICAID EMR INCENTIVE PROGRAMS 1 Regina Gurvich, MBA CHC Chief Compliance Officer, AdvantageCare Physicians Monitoring compliance with Meaningful Use requirements Audit-ready documentation retention to support meaningful use and Clinical Quality Measure attestations Risk-avoidance pitfalls of False Claims Act liability 2 1

2 I CERTIFY THAT the foregoing information is true, accurate, and complete. I understand that the Medicare EMR Incentive Program payment requested will be paid from Federal funds, and that the use of any false claims, statements, or documents, or the concealment of material fact used to obtain Medicare EMR Incentive Program payment, may be prosecuted under applicable Federal or State criminal laws and may be subject to civil penalties. 3 STAGED APPROACH TO MU Stage I EMR adoption, data capturing, and sharing Stage II 2014 Promoting of information sharing between providers, patient engagement, and advanced clinical processes Stage III 2016 Improving health outcomes 4 2

3 ELIGIBILITY, HOSPITALS Medicare Medicaid Hospitals paid under Inpatient Prospective Payment System (IPPS) Critical Access Hospitals (CAHs) Medicare Advantage (MA Affiliated) Hospitals Acute care hospitals (including CAHs and cancer centers) with >10% Medicaid volume Children s Hospitals (No Medicaid volume requirement 5 ELIGIBILITY, PROFESSIONALS Medicare Medicaid Doctors of Medicine or Osteopathy Doctors of Dental Surgery or Dental Medicine Doctors of Podiatric Medicine Doctors of Optometry Chiropractors Physicians Nurse Practitioners Certified Nurse Midwives Dentists Physician Assistants 6 3

4 INCENTIVE OPPORTUNITY Medicare $44,000 For eligible provider Over a 5 year period Maybe subject to a 2% sequestration cut Medicaid $63,750 For eligible Medicaid professionals Over a 6 year period 7 MU MEASURES Percentage based measures Yes/ No measures and Risk-Assessment 8 4

5 CMS AUDIT INITIATIVE 9 THE 5% OIG criticism of lack of CMS oversight CMS to audit Medicare & dual providers States to audit Medicaid providers participating in Medicaid EMR program 10 5

6 CMS PRE-PAYMENT AUDITS Edits in place to scrub for eligibility, reporting, and payment Additional edits targeting last minutes submissions Random Targeting anomalous data Supporting documentation for both pre- and postpayment audits must support MU eligibility criteria Clinical quality 11 WHAT TO DO WHEN YOU GET AUDITED DO s DON Ts Establish timeline for response Gather primary source documents Verify accuracy against original submission Know thy measures Centralize coordination of response Re-create the documents Backdate/ change records Ignore discrepancies Act in silo Miss opportunity to appeal adverse result! 12 6

7 PRIMARY SUPPORTING DOCUMENTATION Numerators and denominators for the measures Time period under report Evidence to support that is was generated for eligible provider NPI, CCN, Provider Name, Practice name Documentation demonstrating data accumulation & calculation 13 MEDICARE AUDIT PROCESS Initial request letter Figliozzi & Co Electronic notification from CMS address Desk review or on-site review Audit Determination letter MU criteria successfully met Recoupment of payment 14 7

8 CMS APPEAL CATEGORIES Eligibility Appeal Meaningful Use Appeal 15 CMS APPEALS For general appeal questions/updates on the status of pending appeals For info on filing appeal and status of pending, Timeframe MU within 30 days after the date of recoupment demand letter Incentive payment calculation within 60 days of determination 16 8

9 MEDICAID APPEAL PROCESS State Medicaid Agencies handle the process COMMON ISSUES & RISKS 9

10 COMMON ISSUES Data security risk assessment Lack of support for yes/no MU criteria 19 SECURITY RISK ASSESSMENT HIPAA vs. Meaningful Use requirement Detailed analysis Specific to Eligible Provider & EMR Stage II vs. Stage I - Encryption/ security of data at rest Assessment must be completed before the end of the reporting period 20 10

11 SECURITY RISK AREAS 21 DOCUMENT RETENTION 6 years post-attestation retention for MU criteria documents supporting MU objectives clinical quality measures EMR contract/ service agreements Clause on documentation retention by vendor 22 11

12 ENFORCEMENT RISK 23 ENFORCEMENT RISK OF AUDIT Referral of fraud cases to CMS or OMIG Enforcement to date Risk associated with FCA: Knowingly Claim Obligation of repayment Obligation of reporting Criminal liability 24 12

13 REFERENCES Programs/ CMS Specification Sheets Federal Register CMS FAQ s ONC FAQ s (healthit.hhs.gov) Federal advisory committee meeting minutes EMR Information Center ( ) EMR Incentive Programs Listserv 25 CONTACT Regina Gurvich, Chief Compliance Officer, AdvantageCare Physicians Phone: [email protected] 26 13