Successfully Navigating MU Audits

July 18, 2017

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Your Bridge to Health IT

Illinois Health Information TechnologyRegional Extension Center (ILHITREC)

SUPPORT PROVIDED BY ILHITREC: ILHITREC is under contract with the Illinois Department of Health

and Family Services (HFS), to provide education, outreach and

support to Medicaid providers for the Electronic Health Record

Medical Incentive Payment Program (eMIPP). ILHITREC partners

with the Illinois Critical Access Hospital Network (ICAHN) and

Central Illinois Health Information Exchange (CIHIE) for support in

this mission and collaborates with the Chicago Health Information

Technology Regional Extension Center based at Northwestern University which serves the City of Chicago.

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Speaker Biographies

Brenda Simms, RN, BSN, CHTS-CP, CMAP

Brenda Simms is a Clinical Informatics Specialist at ILHITREC. She

works with physicians, practice managers, clinical staff, billing

representatives, physicians and EHR vendors to successfully

plan, coordinate and implement an electronic health record

(EHR) system, as well as assist practices with workflow redesign

and development of required quality reporting. Brenda also

worked for a time with the Central Illinois Health Information

Exchange (CIHIE) to facilitate the implementation and effective

adoption of HIE.

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LEARNING OBJECTIVES

• Discuss the Audit Process

• Discuss steps to take in preparing for an audit

• Discuss what to expect during an audit

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“You Cannot EscapeThe Responsibility Of Tomorrow By Evading It Today."

Abraham Lincoln

• The time to prepare for an audit is before you receive the letter.

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HISTORICAL SUMMARY

• The Electronic Health Record Medicaid Incentive Payment Program was implemented through the American Recovery and Reinvestment Act of 2009 (ARRA)

• Incentive Payments for the 2 tier program are:

• Medicare = $44,000 over five years; Last year for payment is attestation year 2016

• Medicaid = $63,750 over six years; Last year for payment is attestation year 2021

• Last year to begin participation was attestation year 2016

• HITECH Act provided assistance to participating providers in the form of Regional Extension Centers (REC)

• 2 RECs in Illinois

• ILHITREC provides services to eligible providers for Illinois outside the City of Chicago

• CHITREC provides services to eligible providers for 606 area code

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AUDITS

• EHR Incentive Program Medicaid Audits will be conducted by:• Department of Healthcare and Family Services

• Office of the Inspector General, Bureau of Medicaid Integrity

• EHR Incentive Programs Medicare Audits will be conducted by:• Figliozzi & Company

• http://www.figliozzi.com/faqs.htm

• OIG Audit of a State’s Medicaid EHR Incentive Program

• Who is Subject to an Audit?• Any eligible provider (EP)

• Any eligible hospital (EH)

• Any eligible critical access hospital (CAH)

• Attesting to and receiving an EHR incentive payment through the Illinois Medicaid EHR Incentive program

• Types of Audits:• Pre-Payment Audit

• Post-Payment Audit 7

BE PREPARED FOR AN AUDIT

Maintain Your Audit Trail:

• The Audit Trail should, read like a story, start at the beginning:

• Provider Eligibility Information

• CEHRT Qualifying Information

• Program Story – Year, Stage and the Reporting Period

• Meaningful Use Objective

• Clinical Quality Measures

• Measure Documentation for the Attestation Year

General Important Information:

• Two People (minimum) should know where the audit file is located and have access to it

• They should be well versed in Meaningful Use, organization workflows and how you achieved the measures

• Should be able to answer questions about the EHR Incentive Program

• They should know attestation process

The information should be readily available – Don’t dig for the information if Auditor performs an onsite8

IF YOU ARE SELECTED FOR AN AUDIT

• Pre and Post Payment Audit Selection• Patient Volume in Illinois is considered a Pre-Payment Audit (100%)

• 10% Random Audit

• Based on Risk Profiles

• Providers may be selected only 1 year or multiple years

• Notification of an Audit• The audit notification is by email, but you may receive a letter

• Notification will go to the email on file for the Provider

• Audit letters should have the official logo of the entity that will be conducting the audit, either Figliozzi (CMS Logo) or HFS/OIG Logo.

• 30 Calendar Day Response Time – Respond Quickly – May request an extension from the Auditor

• Missing Deadlines or Failure to Respond may cause an unfavorable outcome!

• The audit may be conducted either through email or on-site or both

• A demonstration may be requested by an on site Auditor – Be Prepared

• Auditor (s) are there to review a certain year, but if they uncover other issues of concern, they have carte blanch to review other matters.

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RESPONSIBILITY FOR PREPARING FOR AN AUDIT

• It is the responsibility of the eligible entity receiving the incentive payment to maintain proper documentation

• Documentation supporting the attestation should be kept for six years (6) post attestation

• Paper and electronic format be maintained

• Block out all protected health information (Follow the instructions on the audit notice)

• Demonstrate that results can not be or have not been manipulated, by saving in a version such as PDF.

• Be prepared to produce other documentation as requested

• The Audit notification will go to the email on file for the provider

• You have 30 Calendar Days to respond to this request

• You may request an extension – Be precise in the reason for requesting an extension

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Date of Audit Letter

Name Address City, Il Zip

Notice of Review

Provider Name Provider NPI

Dear Provider,

This notice is to inform you that your Medicaid EHR Incentive Program application for program year 2014 has been selected for a post

payment audit. It is the goal and mandate of the program to minimize fraud, waste, and abuse, and your cooperation will be greatly

appreciated in this endeavor. We hope to work as partners with you and your staff to ensure the integrity of the program in the most

efficient manner.

Please read the following documentation request carefully. We request that you provide this documentation within thirty calendar

days of this notice. If you are unable to complete the request, please e-mail us requesting an extension as soon as possible.

All providers selected for audit will need to send the following information via secure e-mail, certified mail or upload the information

directly into the application software:

•A copy of the purchase agreement contract with the vendor from whom the Certified E.H.R. Technology was purchased

• A signed attestation letter regarding audit documentation (See Attached)

Office of Inspector General

Illinois Department of Healthcare and Family Services

2200 Churchill Rd, Bldg A-1 Springfield, Illinois 62702

www.state.il.us/agency/oig

Bruce Rauner

Governor

Bradley K. Hart

Inspector General

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•Report of total encounters from all sites included in the 90-day reporting period attested to in the

application. To accelerate the audit process, the report should include:

• Payer (Medicaid, private health insurance etc.,)

• MCO information (if applicable)

• Billing and Rendering NPI

• Place of Service Code (if applicable)

• Patient Name

• Date of Service

• Patient Date of Birth (MM/DD/YYYY)

•For FQHC/RHC providers only: Reports that verify each of the "needy individual" population

included in the registration. Needy individuals include:

• Sliding Fee scale encounters

• Charity care encounters

• Children's Health Insurance Program (CHIP) encounters

•If the attestation provider is a Physician Assistant (PA), provide administrative documents

(invoices, organizational charts, staff meeting minutes, etc.,) demonstrating the PA role in the

facility

•If during the program year the eligible professional attested to Meaningful Use (MU), please

submit all reports used to populate the state level eMIPP application for the various attested MU

measures

Audits will be rated either satisfactory or unsatisfactory. Please be advised that an audit may be ruled

unsatisfactory for reasons including, but not limited to: incompleteness of information, failure to

comply with deadlines, or gross discrepancies between the documentation and the attested data. Any

unsatisfactory audit may lead to penalties up to and including full recovery of the incentive payment.

You will have the opportunity to appeal any unsatisfactory audit by using the Requests and Appeals

function within the EHR module.

Your cooperation throughout this process is greatly appreciated. If you have questions or need any

additional information, please contact HFS.OIG.Audit@Illinois.gov.

Thank you,

Office of the Inspector General

Illinois Department of Healthcare and Family Services

Medicaid EHR Incentive Program

ATTESTATION OF SUPPORTING DOCUMENTS

I hereby attest that all of the documentation that I/my facility have uploaded to the eMIPP system,

mailed, emailed or faxed to the Illinois Department of Healthcare and Family Services Office of the

Inspector General is, to the best of my knowledge, complete, accurate, and unabridged. I furthermore

acknowledge that all providers and/or facilities are fully aware an unsatisfactory audit may result in

penalties up to and including full repayment of the incentive payment received, for which each

individual provider and/or facility is responsible. I also acknowledge any provider has the right to

appeal an unsatisfactory audit by using the Requests and Appeals function with the eMIPP system.

Provider/Facility

Director's/Supervisor's Name (printed)

Director's/Supervisor's Signature

Date

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SUGGESTED DOCUMENTATION

Disclaimer: Utilization of this document does not guarantee that the Eligible Entity will pass a CMS or State of Illinois Audit

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NON-PERCENTAGE MEANINGFUL USE DOCUMENTATION

Objective Threshold Requirement Suggested Documentation

Meaningful Use Dashboard Numerators and Denominators Generated from CEHRT

Referred to by CMS as “Source Documentation”

• Actual Meaningful Use Report Clearly identifying:• Reporting Period• Eligible Entity Name with NPI • Date Report was generated/printed• Documentation to support any Exclusions taken• Patient Lists (Stage 1) How list was generated/purpose

CEHRT Appropriate for Year of Attestation • Page from CPHL/CMS Certification ID Number

• Vendor Documentation• List of Type of Clinical Lab Tests Incorporated• Screen Shot of report prior to running the report

Screen Shots Prior/During Reporting Period • Show Clinical Decision Support (CDS) rules enabled dated prior to reporting period

• Drug/Drug; Drug/Allergy and Drug Formulary Enabled• Name of Formulary Vendor• Screen Shot of report prior to running the report

Hospital Payment Calculation • Documents supporting Cost Reports• Hospital calculation worksheet 16

NON-PERCENTAGE MEANINGFUL USE DOCUMENTATIONObjective Threshold Requirement Suggested Documentation

HIPPA Security Risk Analysis (SRA) • Physical Inspection Report• Report documenting procedures performed during

analysis, evidence it was generated for provider’s system identified by:• CMS Certification ID (CCN)• Provider Name• Practice Name, TIN, etc.

• List of security deficiencies/mitigation plan/updates• Standards followed when conducting SRA• How Encryption/security of data at rest addressed (Stage

2)• Remember Printers and Fax machines have hard drives,

how do you protect PHI?

Registry Reporting:1. Immunization Registry2. Syndromic Surveillance Reporting3. Specialized Registry4. Electronic Reportable Lab

Reporting (Hospitals/CAHs Only)

Active Engagement • Date screenshots from EHR • Dated record of successful electronic submission• Letter or email public health agency or registry confirming

successful transmission including date of submission, sending and receiving party

Exclusions

Alternate Exclusions

Documentation to support each exclusion to a measure claimed by the provider

Document to support exclusion

• Reports from CEHRT system showing denominators of zero• Public Health Letter documenting provider unable to

submit and would qualify for exclusion

• CMS will not require documentation that provider did not intent or plan to attest to menu objective to claim alternate exclusion

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ELIGIBILITY DOCUMENTATIONObjective Threshold

Requirement

Suggested Documentation

Eligibility Requirements

Locations

Physician Assistant

Hardship Exemption

Support Eligibility

Single or Multiple

PA Lead

Year Filed

• List of Eligible Providers or Facility with NPI, CMS ID#• Tax ID Number (TIN)

• Group Definitions with list of group members

List of all locations in which EP encounters occurred

Documentation FQHC or RHC is PA Lead if PA requesting eligibility

• Copy of the Application and any supporting documentation submitted

Patient Volume Requirements Minimum 30% Medicaid20% Pediatrician

• Reports that support calculations of Medicaid and total patient encounter volumes, explanation of how and when they were generated

• Table 4 of UDS Report for FQHC (s)

EHR System Purchased for AIUIn place for MU

• Documentation to prove Acquisition examples:• Contract documents• Documents supporting Invoice• Documents supporting Purchase Order• Lease documents• License documents

Hospital Payment Calculation • Documents supporting Cost Reports• Hospital calculation worksheet

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SUGGESTED DOCUMENTATIONMEANINGFUL OBJECTIVES

Utilizing 2017 Meaningful Objectives as the Example

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MEANINGFUL USE OBJECTIVES DOCUMENTATION

Objective Threshold

Requirement

Suggested Documentation

Patient Electronic AccessProvide Patient Access

View,Download,Transmit (VDT)>50%At Least 1 Patient

• Sample of a Clinical Summary (de-identified)• Define how and when given to patient• Pertinent Policy and Procedures

Public Health Reporting• Immunization Reporting

• Syndromic Surveillance Reporting• Specialized Registry Reporting

• Electronic Reportable Lab Resulting Reporting

Public Health Reporting to 3 Registries

Exclusions Do Not Count as Meeting Measure

• Actual Email to Public Health to verify engagement• Documentation to show level of Engagement with Registry:

• Options for Engagement:1. Completed Registration to Submit Data – Must be

completed 60 days after starting reporting period2. Completed Testing and Validation3. Production4. https://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/CentralizedRepository-.html

Additional Suggestions ObjectivesClinical Quality Measures

1. Objective/CQM Documentation from CMS listing 2. Specs for that Criteria3. Any FAQs from CMS that were used to interpret questions

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EH/CAH MEANINGFUL USE OBJECTIVES DOCUMENTATION

Objective Threshold Requirement Suggested Documentation

Protect Patient Health Information Yes/No Attestation • Physical Inspection Report• List of Security deficiencies and action plan how they are

mitigated (Review/Updated)

Electronic Prescribing >50% • Screen Shots of Drug/Drug and Drug/Allergy functionality enabled during entire reporting period

• Screen Shots or Documentation verifies drug formulary was enabled, dated prior to the beginning of the reporting period and during entire reporting period

• Name of Formulary Vendor (ex: Superscripts)

Health Information Exchange >10% • Example of Summary of Care (De-identified)• List of sharing partners• Policy/Procedure of how and when exchanged• Documentation to support exchange of key clinical info

Patient Specific Education >10% • Policy/Procedure of how Patient Education is distributed• Source of Patient Education (commercial/designed)

Medication Reconciliation >50% • Policy and Procedure and/or workflow for Med Rec21

DOCUMENTS TO UPLOAD WITH ATTESTATIONS

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DOCUMENTATION TO SUBMIT WITH ATTESTATIONMecky Lang: Contact Method: hfs.ehrincentive@illinois.gov

There could be more than 1 reason attestation is rejected – Read Your LetterAfter An Attestation is Submitted, Documents May be Uploaded in the eMIPP Tracking Mode

Objective Screen

Requirement

Upload Documentation

Patient Volume

FQHC/RHC Only

FQHC

Eligibility Screen in eMIPP Upload the patient volume reports used:1. Shows the 90 day reporting period (Summary, etc.)2. Report used to determine volume3. Report-Total Encounters from all sites for 90 reporting period:

1. Payer2. Medicaid Managed Care Information (If applicable)3. Billing and Rendering NPI4. Place of Service (If applicable)5. Patient Name6. Date of Service7. Patient Date of Birth (MM/DD/YYYY)

4. Report to Verify “Needy Individuals”1. Sliding Fee Scale Encounters2. Charity Care Encounters

3. Children’s Health Insurance Program (CHIP) encounters

**** Table 4 of UDS Report Uploaded – Submission w/o Rejected

Physician Assistant (PA) Attestation Eligibility Screen in eMIPP 1. Administrative Documents Demonstrating the PA Role in the Facility:

1. Invoices2. Organizational Charts

3. Staff Meeting Minutes

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DOCUMENTATION TO SUBMIT WITH ATTESTATIONMecky Lang: Contact Method: hfs.ehrincentive@illinois.gov

There could be more than 1 reason attestation is rejected – Read Your LetterAfter An Attestation is Submitted, Documents May be Uploaded in the eMIPP Tracking Mode

Objective Screen

Requirement

Upload Documentation

Attestation Year for AIU Eligibility Screen in eMIPP 1. Documentation supporting Certified EHR:1. Lease2. Contract3. Purchase Order4. Training Invoice

Attestation to Meaningful Use Meaningful Use TabCQM Tab

1. Actual Meaningful Use Dashboard Report/Date Run from CEHRT System

2. Shows Reporting Period3. Provider Name/NPI4. Actual Numerators and Denominators for MU and CQMs5. Documentation to Support “Yes” or “No” attestations

Public Health Reporting Public Health Reporting Tab

• Actual Email to Public Health to verify engagement• Documentation to show level of Engagement with Registry:

• Option of Engagement 1-4 on slide #16• Proof of Specialized Registries

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Clinical Decision Support DRUG ALLERGY CHECK

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SCREEN SHOT EXAMPLES

MU ATTESTATION SUMMARY REPORT GENERATED BY eMIPPS

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Responding To An Audit

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Audit Information

Email Questions: HFS.OIG.Audit@Illinois.gov

• Sending information to OIG - Preferred methods are:

• Upload documents – either in the audit tab or regular upload documents tab

• State file transfer portal – Available at this link: (https://filet.illinois.gov/filet/pimupload.asp ).

• Secure email

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eMIPP Audit Tab

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Audit Results = No Adverse Findings

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eMIPP Audit Tab - Comments

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eMIPP Audit Tab - Documents

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eMIPP Audit Tab- Example of Uploaded Documents

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If I Have Already Attested, Can I Upload Documents?

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Yes, You Can Upload Documents Through the Tracking Mode

APPEAL PROCESS

• If the Provider fails the audit – There is one (1) appeal opportunity – Make it Count

• Respond quickly and be precise in your rebuttal

UNSATSIFACTORY AUDIT RESULTS

• What Happens if a Provider Fails an Audit after Appeal?

• The payment will be recouped from the provider or the entity receiving payment if the provider does not meet requirement criteria

• The payment for all years may be required to be re-paid under certain circumstances

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WHAT HAPPENS IF I FAIL AN AUDIT?

WHAT HAPPENS IF I FAIL THE AUDIT

• One opportunity to appeal – Make it Count

• Audits will be rated either Satisfactory or Unsatisfactory

• Audits Ruled Unsatisfactory for reasons including but not limited to:

• Incompleteness of Information

• Failure to Comply with Deadlines

• Gross Discrepancies between the documentation and the attested data

• Eligible entity may be required to repay the incentive payment for failure to meet requirements

• Eligible entity may be required to repay all years of incentive payment if requirements for the year being audited or fraud is detected

• The intent of the Auditor is to review the designated attestation year – if something else is uncovered, the Auditor may investigate whatever he or she determines is necessary

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OIG HER Incentive Program Audit Information

https://www.illinois.gov/hfs/SiteCollectionDocuments/EHRIncentiveProgramAudits.pdf

HFS ILLINOIS MEDICAID TOOLKIT

https://www.illinois.gov/hfs/MedicalProviders/eMIPP/Pages/default.aspx

• Most Current Version

• Audit Information Page 57+

• Read Appendix A and B

• BE PREPARED – You may be asked for additional documentation.

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AUDIT REFERENCES

• Official CMS EHR Incentive Website:

• https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/

• Audit Information:

• https://www.illinois.gov/hfs/SiteCollectionDocuments/EHRIncentiveProgramAudits.pdf

• Illinois EHR Incentive Program Tool Kit (Version 8.2, March 27, 2017): Audits page 43-44

• https://www.illinois.gov/hfs/SiteCollectionDocuments/2016EHRIncentiveProgramToolkit.pdf

• CMS = https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/AppealsAudits_2015through2017SupportDoc.pdf

• https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/AppealsAudits_EHRAppealsOverview-.pdf

• Certified Health IT Product List

• https://chpl.healthit.gov/#/search

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Questions?

Contact

Information:

Brenda Simms

bsimms@niu.edu

Kerri Lanum

klanum@niu.edu

Emily Fricker

efricker@niu.edu

General

www.ILHITREC.org

info@ILHITREC.org

(815) 753-590041