How to prepare for an EHR incentive audit

Transcription

1 How to prepare for an EHR incentive audit What is an EHR incentive program? The Medicare and Medicaid EHR Incentive Programs provide incentive payments to eligible professionals, eligible hospitals, and critical access hospitals (CAHs) as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology. Eligible professionals can receive up to $44,000 through the Medicare EHR Incentive Program and up to $63,750 through the Medicaid EHR Incentive Program. How many professionals and hospitals are participating in the EHR incentive program? As of March 2013, more than 259,000 health care providers received payment for participating in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. More than 264,000 eligible professionals have registered for the Medicare EHR Incentive Program as of March More than 124,000 EPs have registered for the Medicaid EHR Incentive Program as of March What is EHR incentive audit? An eligible professional (EP), eligible hospital, or critical access hospital (CAH) attesting to receive an incentive payment for either the Medicare or Medicaid Electronic Health Record (EHR) Incentive Program may be subject to an EHR incentive audit. The Center for Medicare & Medicaid Services (CMS) and its contractor, Figliozzi and Company, are

2 performing audits on Medicare and dually-eligible (Medicare and Medicaid) providers who are participating in the EHR Incentive Programs. States and their contractors will perform audits on Medicaid providers participating in the Medicaid EHR Incentive Program. What type of audits is conducted? Pre-audit CMS has begun pre-payment audits in 2013, starting with attestations submitted during and after January These pre-payment audits will be random and may target suspicious or anomalous data. Providers selected for pre-payment audits will have to present supporting documentation to validate submitted attestation data before CMS will release payment. Post-audit CMS through its contractor is also conducting post-payment audits during the course of the EHR Incentive Programs. Providers selected for post-payment audits will also be required to submit supporting documentation to validate their submitted attestation data. What are the steps involved the audit process? 1 Initial request for documents 2 Initial review process by CMS/Medicaid auditors 3 On-site review (if required) 4 Audit determination letter (eligible or ineligible)

3 What documents will be requested? This primary document will be the starting point of most reviews and should include, at minimum: 1 The numerators and denominators for the measures 2 The time period the report covers 3 Evidence to support that it was generated for that EP, eligible hospital, or CAH (e.g., identified by National Provider Identifier (NPI), CMS Certification Number (CCN), provider name, practice name, etc.) How will the document be reviewed? An audit may include a review of any documentation needed to support information that was entered in the attestation. The level of the audit review may depend on a number of factors, and it is not practical to include an all-inclusive list of supporting documents. The primary documentation that will be requested in all reviews is the source document(s) that the provider used when completing the attestation. This document should provide a summary of data that supports the information entered during attestation. Ideally this would be a report from the certified EHR system, but other documentation may be used if a report is not available or if information entered differs from the report. While the summary document is the primary review step, there could be additional and more detailed reviews of any of the measures, including medical records and patient records. The provider should be able to provide documentation to support each measure to which he or she attested, including any exclusions claimed by the provider. A few examples of suggested documentation are listed below:

4 Please note that the suggested documentation does not preclude CMS or its contractor from requesting additional information to validate attestation data. Meaningful Use Objective Drug-Drug/Drug- Allergy Interaction Checks and Clinical Decision Support Report ambulatory or hospital clinical quality measures Electronic Exchange of Clinical Information Audit Validation Functionality is available, enabled, and active in the system for the duration of the EHR reporting period. Clinical quality measure data is reported directly from certified EHR systems. One test, performed during the EHR reporting period, of certified EHR technology s capacity to Suggested Documentation One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation. Report from the certified EHR system to validate all clinical quality measure data entered during attestation. -Dated screenshots from the EHR system that document a test exchange of key clinical information (successful

5 Protect Electronic Health Information electronically exchange key clinical information with another provider of care with its own distinct certified EHR or other system capable of receiving the information. Security risk analysis of the certified EHR or unsuccessful) with another provider of care during the reporting period. - A dated record of successful or unsuccessful electronic transmission (e.g., , screenshot from another system, etc.). - A letter or from the receiving provider confirming a successful exchange, including specific information, such as the date of the exchange, name of providers and whether the test was successful. Report that documents the procedures performed during the

6 Drug Formulary Checks Generate Lists of Patients technology was performed prior to the end of the reporting period Functionality is available, enabled, and active in the system for the duration of the EHR reporting period. One report listing patients of the provider analysis along with the results. This report should be dated prior to the end of the reporting period and include evidence to support that it was generated for that provider s system (e.g., identified by National Provider Identifier (NPI), CMS Certification Number (CCN), provider name, practice name, etc.) One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation. Report from the certified EHR system

7 by Specific Conditions Immunization Registries Data Submission, Reportable Lab Results to Public Health Agencies, and Syndrome Surveillance Data Submission with a specific condition. One test of certified EHR technology s capacity to submit electronic data and follow-up submission if the test is successful. that is dated during the EHR reporting period, selected for attestation. Patient-identifiable information may be masked/blurred before submission. Dated screenshots from the EHR system that document a test submission to the registry or public health agency (successful or unsuccessful);should include evidence to support that it was generated for that provider s system (e.g., identified by National Provider Identifier (NPI), CMS Certification Number (CCN), provider name, practice name, etc.).

8 - A dated record of successful or unsuccessful electronic transmission (e.g., screenshot from another system, etc.); should include evidence to support that it was generated for that provider (e.g., identified by National Provider Identifier (NPI), CMS Certification Number (CCN), provider name, practice name, etc.). - Letter or from registry or public health agency confirming the receipt (or failure of receipt) of the submitted data,

9 Exclusions Documentation to support each exclusion to a measure claimed by the provider. including the date of the submission, name of parties involved, and whether the test was successful. Report from the certified EHR system that shows a zero denominator for the measure or otherwise documents that the provider qualifies for the exclusion. What could be the outcome of EHR incentive audit? Once the audit is concluded, the provider will receive an audit determination letter from the audit contractor. This letter will inform the provider whether they were successful in meeting meaningful use of electronic health records. If, based on the audit, a provider is found to be not eligible for an EHR incentive payment, the payment will be recouped. CMS may also pursue additional measures against providers who attest fraudulently to receive an EHR incentive payment. It is considered a crime to defraud the Federal Government and its

10 programs. Punishment may involve imprisonment, significant fines, or both. Criminal penalties for health care fraud reflect the serious harms associated with health care fraud and the need for aggressive and appropriate fraud prevention. In some states, providers and health care organizations may lose their licenses. Convictions also may result in exclusion from Medicare participation for a specified length of time. Medicare fraud may also result in civil liability. (Click here for more information about Medicare Fraud & Abuse.) Can we appeal the audit results? CMS has an appeals process for EPs, eligible hospitals, and CAHs that participate in the Medicare EHR Incentive Program. Providers may contact the EHR Information Center through a toll free number, , between 9 a.m. and 5 p.m. EST, Monday through Friday, for general questions on how to file appeals or the status of any pending appeals. States will implement appeals processes for the Medicaid EHR Incentive Program. Medicaid program participants should contact their State Medicaid Agency for more information about these appeals. How frequently the audit is conducted? There is no published guideline on how frequently the audit will be conducted. However, all the program participants are expected to maintain the required documentation for the entire payment period.

11 How can EHR 2.0 help you? EHR 2.0 helps providers and hospitals meet meaningful use attestation requirements by reviewing the incentive submission process, conducting risk analysis and supporting during CMS EHR incentive audit process.