What Healthcare Providers Need to Know About CMS' Pre-Payment Audits

In March, CMS' Office of E-Health Standards and Services announced that between 5 percent and 10 percent of eligible professionals participating in the Medicare and Medicaid Electronic Health Record Incentive Programs will be selected to undergo an audit before the incentive payments are made.

Pre-and post-payment audits
Pre-payment audits will be conducted in addition to post-payment audits — those conducted after the incentive payments have been received by eligible providers. CMS has been conducting post-payment audits since 2012 to ensure providers receiving incentives have indeed demonstrated meaningful use of EHRs, according to Robert Anthony, deputy director of the health IT initiatives group in CMS' Office of E-Health Standards and Services. "We wanted to limit fraud or financial abuse of the incentives," he says.  

CMS implemented the post-payment audits to help establish protocols for the incentive programs. The pre-payment audits help make the existing audit protocols more robust, says Mr. Anthony, and help CMS ensure due diligence on both sides of the payments.

What providers need
Documentation is the most important aspect of these audits, and eligible providers should make sure that they have kept the documents they used for attestation, says Mr. Anthony. CMS has created an online resource, called Supporting Documentation for Audits, which provides information about what documentation to save. "People struggle with documentation," he says.

Documentation needs to be dated and be specific to each provider's practice. According to Mr. Anthony, to ensure that documents are appropriately dated and specific, healthcare providers need to be attentive to their systems. For example, some systems provide a "snapshot in time," which means that the physician can go back to this information at any point, however, some systems are rolling, wherein the information changes with regard to changes made. For rolling systems, providers should keep a copy, on paper or in electronic form, of the information they used for attestation. Being able to substantiate your numbers is one of the best tactics for getting through an audit, says Mr. Anthony.

Selections for audits
So how will CMS select eligible providers for pre- and post-payment audits?

"CMS will make both random and targeted selections," says Mr. Anthony. Targeted selections will be made using risk profiles developed by CMS, which were made with regard to suspicious or anomalous data.

Since the inception of the Medicare and Medicaid Electronic Health Record Incentive Programs in 2011, more than $13.7 billion has been paid to a total of 259,630 eligible providers. Though this is a sizeable number, CMS does expect the number to keep growing, says Mr. Anthony, making it essential for CMS to ensure that the payments are being made in an ethical manner.

More Articles on Audits:

Craneware Webinar to Highlight Outpatient Medical Necessity Audits
HIPAA Compliance: What Providers Should Know About HITECH Act Mandatory Audits

How Will Value-Based Purchasing Impact Internal Audits?

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