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Self-Reporting, Switching Programs Led to Overpayment Under EHR Incentive Program

June 30, 2017:

Eligible professionals (EP) who did not comply with federal meaningful use regulations received an estimated $729 in erroneous incentive payments from May 2011 through June 2014, according to the Office of Inspector General. The agency released a report in June detailing its findings. OIG reviewed such payments to assess the effectiveness of the Centers for Medicare and Medicaid Services’ oversight of the Medicare electronic health records (EHR) incentive program.

The erroneous incentive payments make up 12 percent of the approximately $6 billion paid out in the time period studied.

Under the incentive program, EPs self-report EHR data through an online system. The erroneous payments arose from a few reasons:

  • EPs did not maintain materials supporting the content of their attestations. Such material included security risk assessments, reports listing all the patients with a certain condition, or patient encounter data relating to the measures they reported under meaningful use.
  • CMS did not conduct in-depth reviews of self-attestations.
  • CMS issued payments for the wrong payment year for some EPs who switched between Medicare and Medicaid incentive programs (EPs may be paid under one or the other even if they qualify for incentive payments under both programs). This means that if an EP switched from receiving incentive payments under the Medicare program to Medicaid payments after year one, CMS paid the EP under the Medicaid program as if he or she were in the first year of the program rather than the second year. This means the providers were receiving the higher first-year payments rather than the lower second-year incentives.

As a result of its review, OIG has recommended that CMS take six actions:

  • Claw back the nearly $300,000 in incorrect payments made to the sampled EPs who did not meet meaningful use requirements.
  • Expand payment recovery to include the total $729 million in estimated erroneous payments.
  • Also recover the estimated $2 million in overpayments because EPs switched from Medicare to Medicaid or vice versa.
  • Use edits to ensure providers are paid under either the Medicare or the Medicaid incentive programs but not both for a given program year.
  • Begin reviewing random samples of EP documentation that supports self-attestations.
  • Make sure EPs understand documentation requirements.

CMS fully agreed with all the recommendations except for the second and fifth ones. The agency argues that it has begun conducting targeted, risk-based audits using nonstatistical random sampling. OIG responds that it does not consider such auditing sufficient to address the scope of the problems it found.


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