By Jose Lopez, Senior Consultant, The Verden Group
In our most recent blog post on Meaningful Use, we looked ahead to potential Stage 3 Attestation requirements. In this post, we’ll take a step back and discuss proper Stage 1 Meaningful Use Attestation documentation and the ugly truth no one wants to hear: CMS plans to audit one in every 20 meaningful use attesters. On the Centers for Medicare and Medicaid Services (CMS) Registration & Attestation Page, CMS states, “any provider who receives an electronic health record (EHR) incentive payment for either the Medicare EHR Incentive Program or the Medicaid EHR Incentive Program may be subject to an audit.”
Meaningful Use Audit Process
Through the use of contractors, CMS will perform audits on Medicare and dually eligible (Medicare and Medicaid) providers. Individual states (through the use of their own contractors) will also perform audits on Medicaid providers. CMS and individual states will also manage appeals processes.
If you are audited, you will receive a letter via email from the audit contractor (using a CMS email address) that will include the audit contractor’s contact information. This letter will be sent to the email address provided during registration for the EHR Incentive Program, so be sure your email address is kept updated.
TVG Pro Tip: Use a general practice email address to prevent missing this important email due to employee or provider turnover!
The letter will request, at a minimum, the following four types of data for the audit (see further below for our recommendations on what documentation to keep):
- ONC-ATCB Certification Documentation from the Office of the National Coordinator for Health IT showing the provider used a certified EHR system for Meaningful Use attestation.
- Supporting documentation used by the provider to attest for the Core Set of Meaningful Use criteria.
- Supporting documentation used by the provider to attest for the Menu Set of Meaningful Use criteria.
- FOR HOSPITALS: Information about the method used to report emergency department admissions, which affects some of the hospital measures.
You will only be given two weeks to submit the request information. The initial review process will be conducted by the audit contractor based upon the information submitted. Additional information might be needed during or after this initial review process, and in some cases an on-site review at the provider’s location could follow. A demonstration of the EHR system could be requested during the on-site review.
If, based on an audit, a provider is found to not be eligible for an EHR incentive payment, the payment will be recouped.
If an eligible professional (EP) or hospital participating in the Medicare EHR Incentive Program chooses to voluntarily change or withdraw their attestation, an attestation amendment form or incentive payment attestation withdrawal form must be completed and sent back along with any incentive payments already received:
- Medicare Attestation Amendment Form: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Attestation_Amendment_Form_2012-08-17.pdf.
- Medicare Incentive Payment Withdrawal Form: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Medicare_EHR_Incentive_Withdrawal_Final.pdf.
- An EP or hospital wishing to change or withdraw their attestation in the Medicaid EHR Incentive Program should contact their state directly to make this request.
CMS has an appeals process for eligible professionals, eligible hospitals and critical access hospitals that participate in the Medicare EHR Incentive Program. For general questions and for information on how to file an appeal, please visit the EHR Incentive Programs Appeals page.
States will implement appeals processes for the Medicaid EHR Incentive Program. For more information about these appeals, please contact your State Medicaid Agency.
What should I do now to ensure proper Meaningful Use Documentation?
Providers selected for an audit will have only two weeks to collect and submit documentation so it’s important that providers collect and keep MU Attestation documents at the time of attestation and not wait until an audit happens to try to scramble and retroactively demonstrate successful attestation.
Providers can be audited up to six years following attestation, so practices should keep these audit-ready files available for each year that each individual provider attests for an EHR Incentive payment. Audit documents may be maintained electronically or in paper form.
TVG Pro Tip: To prevent the risk of modification to audit documents, save documents in a format that is not modifiable such as a locked PDF and/or paper copy.
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 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 an eligible professional, eligible hospital, or critical access hospital.
The California Health Information Partnership and Services Organization has made available a http://calhipso.org/HealtheServices/MU_Audit_Preparation_Checklist_V1.4.pdf to help providers prepare for a CMS audit of Stage 1 Meaningful Use attestation. This checklist can help providers organize these records, but utilization of this checklist does not guarantee the EP will pass a CMS Audit.
If you would like assistance with this process, the Verden Group can help. Contact us today for help with collecting and documenting your Meaningful Use Attestation so they will be on hand in the event of an audit.