Auditing PQRS & Meaningful Use To Maintain Compliance. Standard Disclaimer. Learning Objectives 12/2/2014

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1 2014 NAMAS Conference Asheville, NC December 9, 2014 Auditing PQRS & Meaningful Use To Maintain Compliance Presented by David J. Zetter, PHR, CHCC, CPCO, CPC, CPC-H, PCS, FCS, CHBC, CMUP Standard Disclaimer This material is designed to offer basic information. The information presented is based on the experience, training and interpretation of the author of governmental programs. Although the information has been carefully researched and reviewed for accuracy and completeness at the time of presentation, neither the author, nor NAMAS or DoctorsManagement accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation. 2 Learning Objectives Gain better understanding of PQRS Responsibilities Gain better understanding of Meaningful Use Responsibilities How to be Proactive How to Prepare and What you will Need for an Audit Be NOT afraid 3 1

2 PQRS No alignment between MU and PQRS Need to know PQRS to audit it Beginning in 2015, the program will begin applying a payment adjustment to eligible professionals who do not satisfactorily report data on quality measures for covered professional services in is the last year to receive a.5% incentive for reporting 4 Eligible Providers Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic PQRS Eligible Providers Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist Certified Nurse Midwife Clinical Social Worker Clinical Psychologist Registered Dietician 5 Eligible Providers Nutritional Professional Audiologists Physical Therapist Occupational Therapist Qualified Speech Language Therapist PQRS 6 2

3 PQRS Eligibility 7 PQRS Reporting Avoiding 2.0% payment adjustment in 2016 Physicians working for more than one organization need to meet the reporting criteria for each tax identification number (TIN) under which (s)he works during the 2014 PQRS program year to avoid the 2016 PQRS payment adjustment for each TIN. 8 PQRS Reporting Measures Groups: entry of 20 unique patient charts (11 of which have to be Medicare Part B FFS patients) Individual Measures Reporting: choose at least 9 individual measures from at least 3 National Quality Strategy (NQS) domains and report at least 50% of the applicable Medicare patient visits 9 3

4 PQRS Reporting Payment Adjustment Avoidance: allows the reporting of at least 3 measures and 50% of eligible patient visits in order to avoid the % payment adjustment (but not gain the incentive) for 2014 PQRS reporting GPRO (Group Practice Reporting Option): groups of 2 or more operating under a single TIN and the same reporting requirements as Individual Measures Reporting, but applied to a group practice 10 PQRS Workflow 11 Record of documentation Measure groups Individual measures Data mine or reports Data entry Proof of submission Live results CMS Feedback Guarantees Mock Audits 12 4

5 PQRS Audits AMA calls to bench PQRS audits Inadequate preparation and response time Conflicting requirements not under physicians control Reporting period challenges PV Modifier is coming 13 Take the money and run? Proof is in the pudding Figliozzi & Company Electronic letter from CMS address Possible on-site review Demonstration of EHR & 10, & 21.9 Success! Audits are here to stay 15 5

6 Checklist Point person MU registration EH s final cost report Medicaid volume calculation Proof of ownership Certification ID 16 Checklist (cont.) Proof of adoption, implementation or upgrade Allowable costs for purchase of CEHRT Medicare share calculation Attestation submission Other administrative evidence 17 When does the process really start? Mock audits Is it too late? Initial review process Additional requests for information/documentation Secure communications process 18 6

7 The Keys CMS -> Medicare and dually eligible Medicaid/Medicare providers States -> Medicaid providers Numerous pre-payment edit checks built into the Programs' systems Detect inaccuracies in eligibility, reporting, and payment. 19 The Keys Great documentation 6 year retention schedule Reports MUST match exactly Snapshots vs rolling totals Report must match organization & provider NPI, Provider or Organization name 20 Ex: Stage 2, summary of patient care records for more than 50% of transitions of care or referrals. Denominator is the total number of transitions and referrals that occurred during reporting period, while numerator is actual number of case summaries sent electronically to other facilities or clinicians. The numerator and denominator translate into a percentage the CMS is looking to confirm 21 7

8 The Keys Yes or No answers Don t fret, just plan ahead Appeals process (one chance) 22 Ex: Requires providers to prove the ability to share clinical data electronically with another care provider that has a different EHR system -- to prove the organization's interoperability capabilities. 23 Possible Documentation (preparation) Copies of EHR purchase invoices Licensing agreement List of offices and use of CEHRT Proof that 50% or more of patient encounters seen using CEHRT Maintain other charts? Proof that 80% of patients seen in period were maintained in CEHRT 24 8

9 Possible Documentation Copies of EHR reports w/ evidence produced for named EP, EH or CAH Reports with patient lists included in numerators and denominators Step-by-step screenshots of EHR system with measures included Copy of security risk analysis for each year being audited 25 Possible Documentation (preparation) Copy of security policies derived from risk analysis Drug-Drug/Drug-Allergy Interaction Checks and Clinical Decision Support Electronic exchange of clinical information Proof of any exclusion 26 Possible Documentation (preparation) Immunization registries data submission Reportable lab results to public health agencies Syndromic surveillance data submission 27 9

10 5 STEPS OF AUDIT SURVIVAL Resist the PURGE Look back Space constraints Audit logs & polling data Attestation evidence Binders vs. PDF 28 5 STEPS OF AUDIT SURVIVAL Plan ahead Produce the data Space constraints Audit logs & polling data Attestation evidence Binders vs. PDF 29 5 STEPS OF AUDIT SURVIVAL The Unexpected Deep dive into risk assessment Proof of focus EHR and modules Audit, report & reaction w/i attestation period Don t trip 30 10

11 5 STEPS OF AUDIT SURVIVAL Upgrades? Think about it. Proof of CEHRT the entire time Which reports to use? Act Fast Quick response to audit request Request an extension Work with the auditor 31 RECAP Reviewed of PQRS Responsibilities Review of Meaningful Use Responsibilities Ready to be Proactive Preparation & Tools Be NOT afraid 32 For Follow-up Questions Contact: David J. Zetter, PHR, CHCC, CPCO, CPC, CPC-H, PCS, FCS, CHBC, CMUP Subscribe to our newsletter at Stay on top with what s going on in healthcare: CEU Index# 38879NKY 33 11