Bookends of the Patient Experience: Improvement Strategies from Admission to ...
North Carolinas Audit Findings_Final
1. North Carolina’s Audit Findings
Zeda Roberson
Health Information Technology Investigation Team
2. Documented Trends
Unable to provide documentation for post-
payment review
Switching between EHRs
Lack of EHR technical support
Outdated contact information
3. Changes Made Due to Audit Findings
Pre-payment audit
Patient volume (PV) numerator and Meaningful
Use (MU) encounters are the same
PV numbers are over/under inflated
Flagged for post-payment audit
Identify group trends
4. Most Common Reasons for
Recoupment
No response
EP does not meet PV/MU requirements
5. Unique Situations/Unusual Findings
Facility shut down
EP switched practices and former and/or
current practice does not provide requested
documentation
Practice attested for EP without EP’s consent
Good afternoon! My name is Zeda Roberson and I am part of North Carolina’s Health IT auditing team with the NC Medicaid EHR incentive program. We like to think we are unique because our entire program was developed and is run “in-house”, from our development, to our pre and post payment auditing staff. In addition, we have implemented a pre payment audit function to our validation process. As providers are attesting to receive incentive payments, we are able to flag them for audit if we see any potential issues with their attestation. We try to address issues as they arise on the front end, in order to prevent recoupment.
When providers are selected for audit, they are assigned a random number and placed in to risk categories, ranging from low, medium, and high and we then audit a specific parentage from each category. Having this “flag for audit’ feature allows us to ensure that providers posing the highest risks are selected to be audited post payment.
At the present time, NC only audits Eps, CMS audits our EHs.
This presentation is a broad overview of our current process. That being said, let’s talk about Documented trends.
Feel free to ask me question
Unable to provide documentation – all of our guidance says that providers need to maintain all documentation for a period for 6 years in the event of audit.
Providers unable to obtain supporting documents because they have changed systems or providers are unable to provide electronic copies of their information so they send hard copies of their printed encounter data.
(2) Providers/ facilities switching systems as they find the system doesn’t have the functionality to meet certain requirements specified by CMS.
LACK OF TECHNICAL SUPPORT- some vendors are unwilling to work with the provider/group in helping them obtain the necessary data. Providers and staff don’t know how to extract the data and run the necessary reports.
Outdated info- Providers have changed locations or switched practices from the initial time of attestation to the time they are audited and have not updated their information with us. We conduct research in NC Tracks, which is our Medicaid payer system and attempt to contact the provider to obtain the necessary documentation.
Over the years we have made some changes to our audit strategy based on real-life examples such as during pre-payment we have added an audit step when an EP has met all requirements of the program, yet things look off. For example, when an EP attests for a PV numerator and MU encounters are the same. We find it hard to believe that providers are only collecting MUC data for their Medicaid population. It is our expectation that this data is collected from their entire population serviced. So, we reach out and have them explain how they came to that conclusion. If the explanation makes sense, we add it to their attestation and pass them. If not, we request additional information and have them show us how they came to that conclusion. We continue with this process until we feel comfortable enough to pass them. The same goes for when an EP attests for PV numbers that is over or under what we can validate.
Another cool feature that we added into our validation portal based off lessons learned is a flagged for audit check box. We use this when the EPs are passing through the portal on the pre-payment end. Since we use our risk categories to determine who will be audited for post-payment, this is a nice features to use to guarantee the attestation will be audited.
We identify group trends. If a provider fails and audit, we have the right to audit others within that same group. For example, we have noticed that if an EP made mistakes calculating their PV then most likely others within the group made the same mistake.
Finally, we shortened the amount of time we give EPs to respond with supporting documentation. Initially we had 60 days from when the notification of audit was sent to close. We determined that EPs don’t need that much time, so we know give them 15 days to respond.
Not meeting requirements- if a provider shows good faith effort, we work with them and allow them to pick another PV reporting period. At the end of the day, we follow the money. If there is a failed audit, we recoup from the individual or facility that received the payment. We do however, allow the provider to voluntarily return the funds or to have them withheld from future claims.
TIE ALL 3 POINT TOGETHER
Each EP must physically sign their attestations. We do not accept 3rd party or electronic signatures. Providers are allowed to designate where their payment goes, whether they assign it to themselves or the group. Once they sign to receive payment, they are confirming that all information is accurate, making them ultimately responsible.
