9/8/2014
“Audit Proof –Questioning the Answers”
September 9th, 2014
Massachusetts eHealth Collaborative (MAeHC)
The Massachusetts eHealth Collaborative was created in 2004 under the
leadership of the American College of Physicians and the Massachusetts
Medical Society, and remains a registered non-profit corporation.
Our mission: To bring together the state’s major healthcare
stakeholders for the purpose of establishing an electronic health
record system that would enhance the quality, efficiency, and safety
of care in Massachusetts
As we all prepare for the future of Healthcare innovation, our experience
gives MAeHC a unique spectrum of skills in policy, management, and
technology. MAeHC currently serves clients in a number of states,
including New Hampshire, New York, North Carolina, Rhode Island,
Missouri, Illinois, and California, in addition to Massachusetts.
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MAeHC Experience
300 Physician EHR implementation – Beth Israel Deaconess Physician
Organization (BIDPO)
Community-wide EHR Implementation and HIE planning project – California
Healthcare Foundation, Queens Hospital New York
HEAL 5 New York – New York State Department of Health and New York eHealth
Collaborative (NYeC)
HEAL 10 New York – Adirondack Region Patient Centered Medical Home Pilot
State-level HIE technical services vendor procurement – Missouri , North Carolina
State Level Health Information Exchange Strategic and Operational Plan
Development – New Hampshire, Massachusetts
Regional Extension Center planning, deployment, and operations – New York,
Massachusetts, Rhode Island, New Hampshire
Quality Data Center (QDC) to provide PQRS, Meaningful Use and ACO reporting
Health Information Exchange management – New Hampshire
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Agenda
Preparing for an EHR Incentive Program Audit
Audit Steps and Documentation
Audit Concerns
MGL Chapter 224
2014 Meaningful Use Final Rule
Discussion & Questions
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Facts About Audits
 More than $16 billion in Medicare EHR Incentive Program payments
have been made between May 2011 and July 2014. More than $8.4
billion in Medicaid EHR Incentive Program payments have been made
between January 2011 and July 2014.
 CMS has set a goal to audit, at a minimum, 5% of EHR Incentive
Program participants.
 Any Eligible Hospital/Eligible Provider attesting to receive an EHR
incentive payment for either the Medicare or Medicaid EHR Incentive
Program can be subject to an audit.
 States perform audits on Medicaid providers participating in the
Medicaid EHR Incentive Program.
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It’s Coming!
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More Facts About Audits
 Pre-payment checks are built into the Medicare and Medicaid
Incentive Programs to detect inaccuracies in eligibility, reporting, and
payment.
 Audits are generated randomly, however they can also be
produced by suspicious data entered during attestation or
Whistleblowers.
 If an auditor finds the provider not eligible for an incentive
payment, the payment will be recouped.
 CMS has an appeals process for eligible providers and hospitals
that participate in the Medicare EHR Incentive Program.
 Each state has an appeals process for the participants in the
Medicaid EHR Incentive Program.
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“Guilty, until proven innocent.”
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Surviving an Audit
 Keep ALL attestation supporting documentation for six years
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Recommendations
 Keep all documentation in one place – paper or electronic
 Assign a point person to manage all attestation information.
 Don’t re-run reports, the numbers can change.
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9/8/2014
Agenda
Preparing for an EHR Incentive Program Audit
Audit Steps and Documentation
Audit Concerns
MGL Chapter 224
2014 Meaningful Use Final Rule
Discussion & Questions
Massachusetts eHealth Collaborative
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Audit Notification
 First contact will usually be an e-mail
from Figliozzi & Company from a CMS email addressed to the e-mail address
provided during registration for the EHR
Incentive Program.
 CMS is also directly conducting audits
 CMS will NOT provide any guidance.
You must work directly with the Auditor
once the notification is received.
 Help is available!
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Initial Documentation Request
Certification
% Rule
Numerator/
Denominator
Risk
Analysis
Yes/No
Exclusion
CMS: EHR Incentive Programs Supporting Documentation For Audits
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What Documentation Should I Have?
All supporting documentation, in either paper or electronic form, used to
complete the attestation of Meaningful Use, including CQM documentation.
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Certification of EHR System
 Proof of installed version and additional software required
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Security Risk Analysis
 Proof that a security risk analysis was performed prior to the end
of the attestation reporting period.
Protect electronic
health information
created or maintained
by the certified EHR
technology through
the implementation
of appropriate
technical capabilities
Standard
Objective
 Updates to previous risk analysis
Conduct or review a security risk analysis
per 45 CFR 164.308 (a)(1) and implement
security updates as necessary including
addressing the encryption/security of data
at rest in accordance with requirements
under 45 CFR 164.312 (a)(2)(iv) and 45 CFR
164.306(d)(3) and correct identified
security deficiencies as part of its risk
management process
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Exclusion Documentation
 Clinical references or Practice Policies
Numerator
Denominator
Population
Exclusion Criteria
Any EP who believes that all
Number of patients in the
Number of unique
3 vital signs, or BP or Ht/Wt
denominator who have at
Patients whose
patients seen by
have no relevance to their
least one entry of their
records are
the EP during the
scope of practice. Any EP
Ht/length and Wt (all ages)
maintained in the
EHR reporting
with no patients 3 or older
and/or BP (ages 3 and over)
EHR.
period
is excluded from reporting
recorded as structured data
BP
Yes / No
Attestation
Exclusion Criteria
X
1) EP does not administer any of the immunizations to any of the populations for
which data is collected by their immunization registry /system, or 2) No
immunization registry /system is capable of accepting the specific standards required
at the start of their EHR reporting period, or 3) no immunization registry provides
timely info on capability to receive immunization data, or 4) no immunization
registry /system that is capable of accepting the specific standards required by
CEHRT at the start of their EHR reporting period can enroll additional EPs
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CCD Exchange
 Workflow process, trading partners, example files
The EP who transitions their
patient to another setting or
provider should supply summary
of care record for each
transition of care or referral
Standard
Objective
EPs must test their ability to electronically exchange key
clinical information at least once prior to the end of the
EHR reporting period. Testing may also occur prior to the
beginning of the EHR reporting period. Every payment
year requires its own, unique test. If multiple EPs are
using the same certified EHR technology in a shared
physical setting, testing would only have to occur once
for a given certified EHR technology.
Measure 3: Perform at least one
instance of exchange with a
provider using EHR technology
designed by a different EHR
vendor or with a CMSdesignated test EHR
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Clinical Decision Support
Use clinical decision
support to improve
performance on highpriority health
conditions
Standard
Objective
 Screen shots, alert audits, and, server logs
Measure 1: Implement 5 clinical
decision support (CDS) interventions
Measure 2: The EP has enabled and
implemented the functionality for drugdrug and drug-allergy interaction checks
for the entire EHR reporting period
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Patient Reminders and Patient Lists
 One report listing patients of the provider with a specific condition.
 Copies of patient letters or phone logs
Use clinically relevant
information to identify patients
who should receive reminders
for preventive/follow-up care
and send these patients the
reminder, per patient preference
Standard
Objective
 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.
More than 10% of all unique
patients who have had 2 office
visits with the EP within the 24
months prior to the beginning of
the EHR reporting period were
sent a reminder, per patient
preference
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Clinical Quality Measures
 Reports showing all numerators, denominators, and exclusions for
individual ambulatory clinical quality measures.
Clinical Quality Measure Name
National Quality Strategy Domain
*TBD – Functional Status Assessment for Complex Chronic
Conditions
Patient & Family Engagement
*NQF 0022 – Avoidance of Use of High Risk Medications
in the Elderly
Patient Safety
*NQF 0419 – Documentation of Current Medications in the
Medical Record
Patient Safety
*TBD – Closing the Referral Loop: Receipt of Specialist
Report
Care Coordination
NQF 0028 – Tobacco Use: Screening & Cessation
Intervention
Population & Public Health
*NQF 0418 – Screening for Clinical Depression & Follow
Up Plan
Population & Public Health
NQF 0421 – BMI Screening & Follow Up
Population & Public Health
NQF 0052: Use of Imaging Studies for Low Back Pain
Efficient Use of Healthcare Resources
NQF 0018: Controlling High Blood Pressure
Clinical Processes & Effectiveness
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Agenda
Preparing for an EHR Incentive Program Audit
Audit Steps and Documentation
Audit Concerns
MGL Chapter 224
2014 Meaningful Use Final Rule
Discussion & Questions
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Follow Up Request
 After the initial review process, you may receive a follow-up letter.
 Auditors may require additional documentation on ANY measure.
 Clarification of provided documentation.
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What Can Raise a Flag?
 Different numbers on the report for the same denominator definition.

Problem list, Medication list, Allergy list, Patient Education
 Odd looking denominators

Office visit denominator lower than unique patients

Denominators are too low

Varying denominators

Reconciliation / Summary of Care denominator greater than office
visits
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Additional Information Request
From CMS Audit Sample:
If you utilize more than one office or other outpatient facility, could
you please supply documentation which proves:
(i) that 50% or more of your patient encounters during the EHR
reporting period have been seen in offices or outpatient facilities
where you utilize a CEHRT system AND
(ii) that more than 80% of your patient records are maintained in a
CEHRT system at each office or other outpatient facility where a
CEHRT system is being used.
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Best Practices
 Have a single POC in charge of the entire audit process
 Auditors are open to suggestions and alternate documentation
 Customized reports - should retain all documentation that
demonstrates how the data was accumulated and calculated
 Work with the vendor to look at the audit trail or obtain letter of
support
 Create documentation for EXCLUSIONS
 Do not send PHI
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9/8/2014
Agenda
Preparing for an EHR Incentive Program Audit
Audit Steps and Documentation
Audit Concerns
MGL Chapter 224
2014 Meaningful Use Final Rule
Discussion & Questions
Massachusetts eHealth Collaborative
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MGL Chapter 224:
AN ACT IMPROVING THE QUALITY OF HEALTH CARE
AND REDUCING COSTS THROUGH INCREASED
TRANSPARENCY, EFFICIENCY AND INNOVATION.
SECTION 108. The first paragraph of section 2 of chapter 112 of the General
Laws, as so appearing, is hereby amended by inserting after the second
sentence the following 2 sentences:
The board shall require, as a standard of eligibility for licensure, that applicants
demonstrate proficiency in the use of computerized physician order entry, eprescribing, electronic health records and other forms of health information
technology, as determined by the board. As used in this section, proficiency, at
a minimum shall mean that applicants demonstrate the skills to comply
with the “meaningful use” requirements, as set forth in 45 C.F.R. Part 170.
[Chapter 112: First paragraph as amended by 2012, 224, Sec. 108 effective
January 1, 2015. See 2012, 224, Sec. 299.
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9/8/2014
Agenda
Preparing for an EHR Incentive Program Audit
Audit Steps and Documentation
Audit Concerns
MGL Chapter 224
2014 Meaningful Use Final Rule
Discussion & Questions
Massachusetts eHealth Collaborative
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2014 Meaningful Use Final Rule
 Changes the meaningful use stage timeline and the definition of
certified electronic health record technology (CEHRT) to allow options
in the use of CEHRT for the EHR reporting period in 2014.
 Sets the requirements for reporting on meaningful use objectives and
measures as well as clinical quality measure (CQM) reporting in 2014
for providers who use one of the CEHRT options finalized in this rule
for their EHR reporting period in 2014.
"Only providers who could not fully implement 2014 Edition
CEHRT for the EHR reporting period in 2014 due to delays in
2014 Edition CEHRT availability.”
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Reasons Not to Fully Implement
 Financial issues or an inability to meet required objectives, measures and
thresholds would not be deemed acceptable options during an audit.
 Broadly acceptable reasons include any relating to the timing of receiving
upgraded software, implementation and testing time, internal training or
establishing new internal workflows.
 EPs who practice in multiple locations on multiple systems may use the
“inability to upgrade” options, unless more than 50% of their encounters
are documented on 2014 Edition CEHRT.
 EPs can declare an inability to upgrade relating to the Stage 2 electronic
submission of summary of care objective (more than 10% of referrals) if
the providers to whom EPs send the summaries are not equipped to
receive them on 2014 Edition CERHT.
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Recommended Documentation
 Letter from EHR vendor including implementation dates
 Letters from trading partners citing EHR availability
 Copies of support tickets for EHR functionality
 Screen shots of error messages
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Agenda
Preparing for an EHR Incentive Program Audit
Audit Steps and Documentation
Audit Concerns
MGL Chapter 224
2014 Meaningful Use Final Rule
Discussion & Questions
Massachusetts eHealth Collaborative
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Useful & Informative Links
Supporting Documentation for Audits
Sample Audit Letter for Eligible Professional
Audit Overview Fact Sheet
Medicare EHR Incentive Program Return Payment/Withdrawal Form
Eligible Professional Appeal Filing Request
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Contact Information
www.maehc.org
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