The Centers for Medicare & Medicaid Services (CMS) has overpaid an estimated $729,424,395 in electronic health record (EHR) incentive payments to eligible providers (EPs) who attested to meeting meaningful use requirements, according to a report released earlier this month by the U.S. Department of Health and Human Services’ Office of the Inspector General (OIG).

The OIG conducted an audit that found multiple avenues through which CMS made overpayments, including rewarding payments to:

EPs Who Could Not Support Their Attestation
EPs must keep documentation supporting their demonstration of meaningful use for six years, but the audit uncovered EPs who received payments despite not maintaining this documentation. The audit also found EPs who could not demonstrate specific meaningful use measures despite attesting to them, such as EPs who could not provide a security risk assessment and EPs who could not prove they had generated at least one report listing patients with a specific condition despite attesting to their capability to do so.

EPs Who Attested to the Wrong Reporting Periods
The Medicare EHR Incentive Program requires EPs to attest to meaningful use based on patient encounters during specific reporting periods. Some EPs attested to 90 days of encounter data instead of a full calendar year as required by the incentive program but still received incentive payments.

EPs Who Didn’t Use EHRs Sufficiently
The primary purpose behind the EHR Incentive Program is to garner widespread use of electronic health records, so EPs must have at least 50 percent of their patient encounters at a location equipped with certified EHR technology during the reporting period. CMS made incentive payments to EPs who didn’t actually meet this requirement.

EPs Who Changed Incentive Programs
Switching incentive programs in itself isn’t the issue when it comes to overpayment. An EP who qualifies for both the Medicare and Medicaid EHR Incentive Programs can switch between programs one time after receiving his first payment. The problem is that CMS restarted the program calendar for some of these EPs, paying the higher first-year incentive amount rather than the lower amount for the correct program year. For example, if an EP received incentive payments for the Medicaid program in 2011, then switched to the Medicare program in 2012, she should receive the second-year incentive amount for 2012, not the higher first-year incentive amount. However, CMS paid many of these EPs the wrong program year incentive amount.

EPs Who Don’t Have Active NPIs
EPs must have an active NPI to qualify for Medicare incentive payments. However, the OIG audit revealed that many deceased EPs received incentive payments due to inconsistent provider data and lack of systems in place to recognize status changes within the National Plan and Enumeration System.

The major challenge behind tracking meaningful use compliance is that attestation is self-reported. When combined with lack of sufficient oversight by CMS, this increases the risk of incorrect incentive payments going to EPs and hospitals that don’t actually meet meaningful use requirements. This is the very reason the OIG conducted an audit of the Medicare and Medicaid EHR Incentive Programs.

In light of these findings, the OIG made six recommendations, four of which CMS has or will implement. Those include:

  • Recovering the $291,222 in payments made to the 100 EPs included in the audit who did not meet meaningful use requirements
  • Recovering the $2,344,680 in overpayments made to EPs who switched programs and received the wrong incentive amount
  • Educating EPs on documentation requirements
  • Updating the NLR system to safeguard against payments being issued to EPs under both EHR incentive programs for the same program year

According to the OIG, these actions are a start, but they don’t go far enough to ensure federal dollars are being used appropriately. Moreover, the OIG’s estimate of $730 million in overpayments is still potentially out there. The OIG’s report states:

“After reviewing CMS’s comments and having followup [sic] discussions with CMS officials, we maintain that the targeted risk-based audits are not capturing errors such as those identified in this report. We therefore continue to recommend that CMS review EP incentive payments to determine which EPs did not meet meaningful use and attempt recovery of the estimated $729,424,395, as well as review a random sample of EPs’ documentation supporting their selfattestations to identify inappropriate incentive payments.”

At present, it doesn’t appear CMS has any plans to do a full audit to find that estimated $730 million in overpayments, but urgent care providers who attested to meaningful use should be aware that a full audit is still a possibility.

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