Audits

How long should I retain documentation for Meaningful Use Attestation?

You must retain ALL relevant supporting documentation to support attestation data for Meaningful Use objectives and clinical quality measures for six years post-attestation.

What type of documentation is required for non-percentage-based measures?

To validate EP attestation for these objectives, CMS and its contractor may request additional supporting documentation.

A few examples of suggested documentation are listed:

• Drug-Drug/Drug-Allergy Interaction Checks and Clinical Decision Support: One or more screenshots from the certified EHR system that demonstrate the enabling of the interventions during the EHR reporting period selected for attestation.
• Report clinical quality measures: Report from the certified EHR system to validate all clinical quality measure data entered during attestation.
• Protect Electronic Health Information: Documentation of security risk analysis of the certified EHR technology was performed prior to the end of the reporting period. 
• Drug Formulary Checks: One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation.
• Generate Lists of Patients by Specific Conditions: Report from the certified EHR system that is dated during the EHR reporting period selected for attestation. Patient-identifiable information may be masked/blurred before submission.
• Immunization Registries Data Submission, Reportable Lab Results to Public Health Agencies, and Syndromic Surveillance Data 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 EP’s system.
  • 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.
  • Letter or email from registry or public health agency confirming the receipt (or failure of receipt) of the submitted data, including the date of the submission, name of parties involved, and whether the test was successful.
• Exclusions - Documentation to support each exclusion to a measure claimed by the EP.

What type of documentation is required for percentage-based measures?

To ensure you are prepared for a potential audit, save any electronic or paper documentation that supports your attestation. The primary documentation that will be requested in all reviews is the source document(s) that the EP 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. You should retain a report from the certified EHR system to validate all clinical quality measure data entered during attestation, since all clinical quality measure data must be reported directly from the certified EHR system.

This primary 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 EP (e.g., identified by National Provider Identifier (NPI), CMS Certification Number (CCN), provider name, practice name, etc.) .

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 EP should be able to provide documentation to support each measure attested, including any exclusions.

Who performs the Medicare EHR incentive programs auditing?

Meaningful Use auditing is performed by Figliozzi and Company. If you are selected for an audit, your facility will receive a letter from them with the CMS and EHR Incentive Program logos on the letterhead.

How will I know if I am being audited by CMS?

If you are selected for an audit you will receive a letter from Figliozzi and Company with the CMS and EHR Incentive Program logos on the letterhead. The request letter will be sent electronically from a CMS email address and will include the audit contractor’s contact information.

Can I be audited prior to receiving a payment?

Yes, CMS conducts random pre-payment audits to validate submitted attestation as well as post-payment audits.

Can I be audited for Medicaid incentive payments?

Yes, states will have separate audit processes for their Medicaid EHR Incentive Program. For more information about these audit processes, please contact your state Medicaid Agency.

What happens if I fail the audit?

Once the audit is concluded, the EP will receive an Audit Determination Letter from the audit contractor. This letter will inform the EP whether they were successful in meeting Meaningful Use of electronic health records. If, based on the audit, an EP is found not to be eligible for an EHR incentive payment, the payment will be recouped. CMS may also pursue additional measures against EPs who attest fraudulently to receive an EHR incentive payment. Punishment may involve imprisonment, significant fines or both. Convictions also may result in exclusion from Medicare participation for a specified length of time. Medicare fraud may also result in civil liability.

Can I appeal the results of an audit?

CMS has an appeals process for EPs, EHs and CAHs that participate in the Medicare EHR Incentive Program. Providers may contact the EHR Information Center through a toll free number, 888-734-6433, between 9 a.m. and 5 p.m. EST, Monday through Friday, for general questions on how to file appeals and 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.

Who should I be expecting to contact me if my facility/provider is in an EHR Incentive Audit?

Figliozzi and Company is who will be performing audits for CMS. If you are selected for an audit, you will receive a letter from them with the CMS logo attached. If you have a question regarding this, questions can be directed to Peter Figliozzi at (516) 745-6400 x302 or at pfigliozzi.com. Their website is http://www.figliozzi.com. This email and letter will come to the person that has registered as the administrator or individual that has filled out the attestation information on the CMS website.

If our facility or provider is audited, who will the initial audit letters come to?

If your facility or provider is in an audit, an initial email will come to the person who registered on the CMS website for the attestation. If that person leaves your facility, or changes, the hospital/provider will need to go back to the CMS website and update the email address.

If my facility/provider is in an audit, what information should I gather to present?

To ensure you are prepared for an audit, save the electronic or paper documentation that supports all of your attestation (including any exclusions). This includes the values you have entered in the Attestation Module. Hospitals should also maintain documentation that supports their payment calculations. If based on an audit, a provider or hospital is found to not be eligible for an EHR incentive payment and has not met attestation, the payment will be recouped.  Initial audit review will be conducted by the auditor at their location. Additional information may be required or needed during or after the initial review process and in some cases, an onsite review at the provider’s location could follow. A demonstration of the EHR system could be requested during the onsite-review.
Any provider or hospital that finds themselves in an audit of their EHR incentive payment, should retain the information found here.

Below are the links to the Evident Audit documentation: 

Meaningful Use Audit Stage 1 - 2014 Eligible Hospitals

Meaningful Use Audit Stage 2 - 2014 Eligible Hospitals

Meaningful Use Audit Stage 1 - 2014 Eligible Professionals

Meaningful Use Audit Stage 2 - 2014 Eligible Professionals

Here is also the link to the Frequently Asked Questions regarding Auditing by CMS.

What if my facility does not pass an audit, can my facility/provider appeal?

CMS has an appeals process for eligible professionals, eligible hospitals and critical access hospitals that participate in the Medicare/Medicaid EHR Incentive Program. If your facility wishes to appeal they must complete the appropriate filing request found in the below link. The appeals submission process is time sensitive with a 30 day window for submission period. The filing request and supporting documentation must be submitted. The appeal will only be processed if all documentation needed is provided at the time of submission.

CMS Appeals Information

What if my hospital/provider does not agree with the amount of EHR incentive funds we have received?

The Centers for Medicare and Medicaid Services do not process appeals for provider’s, hospital’s or CAH’s who dispute the amount of their EHR inventive payment. After an EP successfully attests, a monthly report determines whether the allowable claims threshold for the program participation year has been met. After the close of the incentive payment year, incentive payments are made based on 75% of Medicare allowed charges for covered professional services furnished during the payment year that have been successfully submitted by the EP. After a hospital or critical access hospital successfully attests, an initial incentive payment is issued based on the latest available cost report which is then reconciled when the cost report is finalized.

Here is the CMS Frequently Asked Question regarding appeals regarding the dispute of the amount of the incentive payment.

Can we keep screen shots in our records to prove we were able to attest to certain objectives in case of audits?

Yes, we recommend that you take screen shots of all objectives met through attestation in case of future audits.