Meaningful Use Survivor: 4 Steps to a Successful Audit
Upcoming SlideShare
Loading in...5

Meaningful Use Survivor: 4 Steps to a Successful Audit



Meaningful Use Survivor: 4 Steps to a Successful Audit

Meaningful Use Survivor: 4 Steps to a Successful Audit



Total Views
Views on SlideShare
Embed Views



1 Embed 2 2


Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
Post Comment
Edit your comment
  • JIM
  • Jim
  • Jim
  • Jim
  • Jim
  • Mary
  • Mary
  • Mary
  • Mary
  • Mary
  • Mary
  • Mary
  • Mary

Meaningful Use Survivor: 4 Steps to a Successful Audit Meaningful Use Survivor: 4 Steps to a Successful Audit Presentation Transcript

  • Patient volume Risk Analysis Patient Reminders Valid license to practice CDSR Meaningful Use Survivor: Four Steps to a Successful Audit
  • Mary Givens, Chief Contributor to, the only meaningful use resource developed specifically for the Behavioral health EP. Also the Meaningful Use Manager at Qualifacts Systems, Inc. Karyn Krampitz Director, Professional Learning Center The Coalition of Behavioral Health Agencies, Inc. 90 Broad St., New York, NY 10004 212.742.1600 x103 office kkramp! Introduction of the Speakers
  • Agenda Topic Audit Program Overview Topic Audit Program Process Topic Create an Audit trail Topic Summary of the Four Steps
  • CMS FAQ7711 ( Any provider attesting to receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Program potentially can be subject to an audit. Here's what you need to know to make sure you're prepared: Overview of the CMS EHR Incentive Programs Audits • All providers attesting to receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Programs should retain ALL relevant supporting documentation (in either paper or electronic format) used in the completion of the Attestation Module responses. Documentation to support the attestation should be retained for six years post-attestation. Documentation to support payment calculations (such as cost report data) should continue to follow the current documentation retention processes.
  • Audit Program Overview • Medicare EHR Incentive Program participantsCMS, and its contractors, will perform audits on Medicare and dually-eligible Medicare/Medicaid providers. • Medicaid EHR Incentive Program participantsStates, and their contractors, will perform audits on Medicaid providers. Variability among the States. • CMS/State Medicaid can audit for up to six years following participation in MU program. • Appeals Process-CMS and each individual state will also manage appeals processes.
  • Audit Program Process Checks built into the attestation process to detect inaccuracies in eligibility, reporting and payment. Pre-payment and post-payment audits are underway. If a provider is found to not be eligible for an EHR incentive payment, the payment will be recouped. CMS has implemented an appeals process for EPs, EHs, and CAHs that participate in the Medicare EHR Incentive Program. States will implement appeals processes for the Medicaid EHR Incentive Program. For more information contact the State Medicaid Agency.
  • Audit Program Process What triggers an Audit? Random Suspicious data Whistleblowers
  • Audit Program Process Who will be audited? • As of July 2013 over 290,000 unique EPs and 4,000 unique EHs have received Medicare incentives. • CMS states the aim is to audit 5% - 10% of participants.
  • Audit Program Process The Audit Process The Letter The Request for Documentation Response and Request Final Determination Appeal Process
  • Audit Program Process If the EP is selected: • If an EP is selected for an audit, the first contact will be an email to the email address provided during the registration at CMS. • The auditing entity will request supporting documentation (paper or electronic) to support the EPs attestation. • Proof of possession of a certified HER • Evidence (audit package) to support each of the measures attested to including evidence if exclusion where relevant. • Proof that the security risk analysis was conducted during the reporting period and if deficiencies were identified, the plan of correction to address these deficiencies, including target completion dates. • Report for clinical quality measures.
  • Audit Program Process Response and Request: • Submitted documentation will be reviewed by the auditing entity and, if necessary, there will be a request of additional information or request for greater clarification.
  • Audit Program Process Final Determination - Good “We performed a desk review on your facility’s meaningful use attestation for the Program Year 2011 and Payment Year 1. Based on our desk review of the supporting documentation furnished by the facility, we have determined that Hospital XYZ has met the meaningful use criteria.”
  • Audit Program Process Final Determination - Bad “We performed a desk review on your facility’s meaningful use attestation for the Program Year 2011 and Payment Year 1. Based on our desk review of the supporting documentation furnished by the facility, we have determined that Hospital XYZ has not met the meaningful use criteria, for the following reasons: Failed Eligible Hospital Meaningful Use Core Measure X. Since your facility did not meet the meaningful use criteria, the incentive payment will be recouped. You will receive a demand for your total Medicare EHR incentive payment shortly from the EHR HITECH Incentive Payment Center. The demand letter will include all information regarding the repayment process, and will also include your appeal rights.”
  • State Medicaid Audit Processes State to state, process will vary • The exact audit process will vary from state to state. The following slides should give you a general understanding of what the process might be like. • At the end of this presentation, we have provided you with the links for many sources of information on audits, including as many state specific audit links as we could find. • You can assume each state will conduct pre payment audits as well as post payment audits on the following: • Provider eligibility • Incentive payments for • Demonstration of A/I/U • Meaningful Use of certified EHR Technology
  • State Medicaid Audit Processes Overview • Medicaid EHR Incentive Program audits are conducted to detect fraud, abuse, or waste of Medicaid dollars. • Each state that chose to participate in the Medicaid EHR Incentive Program has a Health Information Technology (HIT) plan that was approved by CMS prior to that state being able to initiate their state Medicaid EHR Incentive Program. • Each of these state HIT plans includes the state’s policies and procedures to ensure that the EHR Incentive payments are issued properly and to prevent fraud and abuse (The State’s Audit Strategy).
  • State Medicaid Audit Processes Pre-Payment Validations When an EP attests in the State Medicaid EHR system for a particular calendar year, he is attesting to the accuracy of that submission. • Before the state releases an incentive payment, it will perform an analysis of the information to verify that it is consistent with state data. • This process ensures that the provider completed the application correctly and accurately and allows for addressing any problems prior to the issuance of the incentive payment. • The process may utilize a combination of automatic and manual validation steps. • Each state will also leverage the existing controls built into the Medicaid enrollment and reimbursement process for items such as Medicaid enrollment status and sanctions or exclusions. • If the state finds a discrepancy or has questions, they will contact the Eligible Professional and ask for additional information and/or documentation. •
  • State Medicaid Audit Processes Post Payment Audits • Eligible professionals should be aware that all information submitted during registration, attestation, supplemental materials, and any subsequent validation and audit procedures must be backed by auditable data sources or documentation. • In light of the possibility of post-payment audit, providers are required to retain documentation in support of all attestations for no fewer than six years after each payment year.
  • Audit Program Basics Create an Audit Trail • Medicaid EP Eligibility: • Retain all documentation used to determine the eligibility of the provider who chooses to participate in the program. • Copy of the CMS registration receipt for each Eligible Professional (EP) • Evidence of valid credential, valid license, and active individual Medicaid ID number at time of attestation • Document verification that provider is non hospital based at time of attestation • Evidence that EP agreed to assign incentive dollars to your agency.
  • Audit Program Basics Create an Audit Trail • EP Patient Volume- Clearly document the process used for calculating patient volume so that the report can be recreated. • This includes defining the formulas and /or queries used for the calculation. • If the BH EP used encounters that were delivered as part of a fixed rate per day program for his/her patient volume calculation, be sure to retain evidence of those encounters. • Be prepared to demonstrate and have evidence of how it is established that the patient was a Medicaid participant on the day the billable service was delivered.
  • Create an Audit Trail • EP Measures: • Retain all paper or electronic format documents used in the completion of each of the attestation modules. This could include but is not limited to • For percentage based measure, copy of the EP Measure report or dashboard • For non percentage based measures, retain any screenshots or other evidence • For risk analysis measure, retain copy of the risk analysis completed during reporting period. • For exclusions EP must also retain evidence. ** Upon audit, the documentation will be used to validate that the provider accurately attested and submitted CQMs, as well as to verify that the incentive payment was accurate.
  • Create an Audit Trail • Primary documentation that will be requested is the source document(s) that the provider used during attestation. • This document should provide a summary of the 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 the information entered differs from the report. • This summary document will be the starting point of most reviews and should include, at minimum: • • The numerators and denominators for the measures • The time period the report covers • Evidence to support that it was generated for that eligible professional. Although the summary document is the primary review step, there could be additional and more detailed reviews of any of the measures, including review of 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. Source:
  • Some examples of the types of documentation that might be expected • • • • • Measures Drug-Drug/Drug-Allergy Interaction Checks and Clinical Decision Support – Proof that the functionality is available, enabled, and active in the system for the duration of the EHR reporting period. Measure Electronic Exchange of Clinical Information – Screenshots from the EHR system or other documentation that document a test exchange of key clinical information (successful or unsuccessful) with another provider of care. Alternately, a letter or email from the receiving provider confirming the exchange, including specific information such as the date of the exchange, name of providers, and whether the test was successful. Protect Electronic Health Information – Proof that a security risk analysis of the certified EHR technology was performed prior to the end of the reporting period (e.g., report which documents the procedures performed during the analysis and the results). Drug Formulary Checks – Proof that the functionality is available, enabled, and active in the system for the duration of the EHR reporting period. Exclusions – Documentation to support each exclusion to a measure claimed by the provider. Source:
  • Sample of some “Prepare for Audit” Tools available In the next couple of slides we will look at a couple of tools developed from other sources to be used to prepare for an audit-
  • *The South Florida REC put out a “Meaningful Use EHR Incentive Program Audit Defense Documentation” checklist that sites “recommended items each provider should complete in order to thoroughly document Meaningful Use attestation.” Lets look at part of this list *
  • Louisiana Medicaid has contracted with Myers and Stauffer LC, an audit firm to review the incentive payments in the LA Medicaid EHR Incentive Program. LA CONNECT published an **“Audit Tips for Eligible Professionals” document. Below is some of the context from this tool-
  • The Illinois Health Information Technology Regional Extension Center (IL HITREC) created a document called, *** “A Meaningful Use Audit Reference Guide: Suggested Documentation to Keep After Attestation”. Let’s look at some of the advice included in this document- ***
  • Four Steps to a Successful Audit 1. Identify who will manage the audit 2. Establish contact with the auditor 3. Comply with the deadline 4. Seek vendor support
  • Questions?
  • DISCLAIMER: Please remember We do our best to provide you with the most accurate information possible, but it is ultimately your responsibility to fully understand and comply with the final rules and regulations of the Medicaid and Medicare EHR Incentive Programs. We highly recommend each individual consult the CMS website and the state-specific Medicaid EHR Incentive Program website to confirm the rules and requirements. Under no circumstances shall anyone associated with of Qualifacts Systems Inc. Be liable for any incidental, indirect, consequential or special damages or loss of any kind including those resulting from the expected incentives themselves. It is important that each Eligible Professional note that CMS views the EP as ultimately responsible for the numerator and denominator and their Medicaid Encounter volume as well as the data used for attestation on the measures of Meaningful Use.
  • IMPORTANT LINKS CMS Guide to the States, “Medicaid EHR Incentive Program Audit Strategy Toolkit”, (revised 1/13) CMS Audit, “What Providers Need to Know about EHR Audits” Why is Making Meaningful Use Audits a Priority Necessary AAFP, “How to Prepare for, Survive an EHR Meaningful Use Audit: Government Expert Provides Tips.” HIMSS, “The Summer Olympic Games Have Begun as Have the EHR Meaningful Use Incentive Audits”
  • Some State Specific Audit Resource LINKS Colorado State Medicaid HIT Plan-includes audit information Kentucky Medicaid EHR Incentive Program Eligible Professional Meaningful Use Attestation Manual New Jersey Audit Process Web Page New York Medicaid EHR Incentive Program Integrity and Audit Guidelines North Carolina Medicaid Electronic Health Record (EHR) Incentive Program Audits Pennsylvania EHR Incentive Program Audits Oregon Medicaid Electronic Health Records Incentive Program Rulebook Division 165 (Audit Information Starts on page 6) Wisconsin: WHITEC Meaningful Use Attestation and Audit Preparation
  • Some State Specific Audit Resource LINKS Virginia : How to Prepare you Practice for Meaningful Use Louisiana: LA Connect Audit Tips for Eligible Professionals Illinois HITEC REC : A Meaningful Use Audit Reference Guide: Suggested Documentation to Keep After Attestation” Tennessee Audit Information South Florida REC Meaningful Use Attestation Audit Defense Documentation Recommendations Incentive_Payment_Checklist.pdf Georgia “Tips for Eligible Professionals Selected for Post Payment Review of the Georgia Medicaid Electronic Health Record Incentive Program Payment”
  • Some State Specific Audit Resource LINKS Texas EHR Incentive Program: Appealing an Audit Finding Texas EHR Incentive Program : Auditing and Supporting Documentation df Idaho EHR Incentive Program Payments Audit
  • Contact Me Mary Givens, Chief Contributor to and Meaningful Use Manager at Qualifacts Systems, Inc. Email Mary at For invitations to future webinars, please subscribe at scribe-General.html