Meaningful Use Audit Webinar Series March 25, 2015: An Overview of the Meaningful Use Audit Process 1 in 10 providers will receive a MU audit letter April 1, 2015: Preparing for EHR Incentive Program Audit Tips and Suggestions The time to prepare for an audit is before you receive the letter April 8, 2015: EHR Incentive Program Appeals Process Steps to Complete a Meaningful Use Audit Appeal

An Overview of the Meaningful Use Audit Process Sam Ross CHITREC Clinical Implementation Manager March 2015

Disclaimer This webinar is based on official guidance provided by the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC), experiences from CHITREC, and other Regional Extension Centers. It is by no means all-inclusive of the types of documentation you must keep to support your attestation, but this webinar provides a starting point. CHITREC is not giving legal advice. If you are audited, you should consult your Certified EHR Technology (CEHRT) vendor and/or legal advisor.

Agenda Overview of Centers for Medicare & Medicaid Services (CMS) Audit Process General Tips Documentation Examples Attestation, Internal Sources, and External Sources

Auditor: Medicare Figliozzi & Company Performs all audits for the Medicare EHR Incentive Program Has a 3-year contract with CMS Started in July 2012 If you are selected for an audit, you will receive a email from Figliozzi & Company with a CMS logo. It will go to the email address listed in your CMS attestation profile. Questions can be directed to Peter Figliozzi Phone: (516) 745-6400 ext. 302 Email: pfigliozzi@figliozzi.com Website: http://figliozzi.com/

Auditor: Medicaid State Agency (in Illinois) Office of the Inspector General (OIG) Illinois Department of Healthcare and Family Services (HFS) If you are selected for an audit, you will receive a email from OIG/HFS. It will go to the email address listed in your Medicaid attestation profile. Questions can be directed to Marybeth Young at Marybeth.Young@illinois.gov or 217.558-5584 Aster Bowden at Aster.Bowden@illinois.gov or 217.557.6615 For more information: http://ww.cms.gov/Regulations-and- Guidance/Legislation/EHRIncentivePrograms/Attestation.html

Audit Process Pre- and post-payment audits are performed for each attestation year; providers will be chosen based on random sampling and risk profiles; you could be audited for multiple years. If an auditor finds the provider is not eligible for an incentive payment, the payment will be recouped from whom or whatever received the payment (the provider or the assigned entity). There is an one time only appeal process that can be used to make your case for the incentive. Centers for Medicare & Medicaid Services. CMS.gov Frequently Asked Questions, 2012. Web. February 13, 2013.

Be Prepared Maintain an audit file Respond promptly Protect personal health information (PHI) Do not miss any deadlines

Audit Trail Start at the beginning to create and maintain clear and lengthy audit trails. Provider eligibility information CEHRT qualifying information Program Information- Year, Stage, Reporting Period MU Core and Menu Report CQM Report Measure Documentation

General Tips Confirm there are at least two people who know the location of the audit file Understand the measures and the workflows used to achieve the measures Be able to explain variances from EHR-generated MU Reports Know about the EHR incentive program and attestation process

Keep Your Audit File SIX YEARS Maintain the source documents you used for completing the attestation for 6 years SIX YEARS

Information Requests The following information is usually included in a request from the auditor: CEHRT reports and dashboards Certification document for the CEHRT The reason a measure numerator and/or denominator differs from the CEHRT report or dashboard for a measure Documentation to support the “Yes/No” measures You have 2 weeks to respond to this request You can request an extension

Information Requests After the initial review process, you may receive: Follow-up emails(s) There could be one or many request for additional documentation or clarification In some cases, an on-site review at the provider’s location follows. A demonstration of the EHR could be requested during an on-site review. The process could take several months before there is a determination.

Documentation Tips Prepare for an audit before and after you attest. Some documentation must be created during your reporting period (screenshots, Yes/No self attestation measures) Some documentation should be gathered for attestation (MU Reports, ONC CEHRT number) Some documentation should be created to show you have attested with the correct information at the correct time (copy of attestation data/screens)

Documentation Tips Make clear and relevant screenshots If possible, make sure the CEHRT is identifiable by logo or product name Make sure the provider name is identifiable in the screenshot Note: On a personal or desktop computer, use the following function to paste the screenshot on a blank Microsoft Office Word document; <Shift + PrintScreen> Keep protected health information (PHI) secure Black out PHI on a copy of the screen shot and send the copy Use secure messaging if requested to send PHI

General Tips Keep a copy of relevant CMS Frequently Asked Questions (FAQ), and check the website periodically for FAQs Do not count on finding the information later https://questions.cms.gov Centers for Medicare & Medicaid Services. CMS.gov Frequently Asked Questions, 2012. Web. February 13, 2013.

General Tips Each CEHRT is different Examples of yes/no measures Develop an understanding of how your CEHRT handles specific documentation and functions Examples of yes/no measures Ask your CEHRT vendor how to document yes/no measures Document that functionality was in place at the start of the reporting period and was not interrupted for the following: Drug-Drug/Drug-Allergy Interaction check Clinical Decision Support Drug Formulary Checks

General Tips Follow 7 fundamental elements of any compliance program Written policies and procedures Compliance professionals Effective training Efficient communication Internal monitoring Enforcement standards Prompt response Office of the Inspector General. Heat Provider Compliance Training, Take the Initiative: Cultivate a Culture of Compliance With Health Care Laws. Web. February 10, 2013.

Key Points CMS conducts audits for the Medicare EHR Incentive Program The State Agency will conduct audits for the Illinois Medicaid EHR Incentive Program Diligently create and maintain documentation for your practice All documents should be maintained for 6 years Periodically monitor the CMS website for new audit information Audit requirements are still being determined, and some gray areas may exist

Resources www.chitrec.org Office of the Inspector General. Health Provider Compliance Training, Take the Initiative: Cultivate a Culture of Compliance With Health Care Laws. Web. February 10, 2013. Retrieved via website: https://oig.hhs.gov/compliance/provider-compliance- training/index.asp Centers for Medicare & Medicaid Services. CMS.gov Frequently Asked Questions, 2012. Web. February 13, 2013. Healthcare and Family Services. myHFS.gov, 2012. Web. February 13, 2013.

About CHITREC The Chicago Health Information Technology Regional Extension Center (CHITREC) is a collaboration among Northwestern University, the Alliance of Chicago Community Health Services and more than 40 local and national partners focused on health IT adoption. Provide education on MU Stage 1 and 2, HIE, PCMH, and more Operate a Meaningful Use Help Desk (855-MU-HELP-1) for the Illinois Medicaid EHR Incentive Payment Program (eMIPP) Help providers attest to MU and earn incentives Build tools and technology that support adoption of HIT and the aggregation of EHR-based data Expand local HIT workforce through a robust internship program CHITREC has helped over 1,200 Chicago providers collect more than $27.5 million in government EHR incentives. CHITREC CAN HELP WITH INFORMATION AND GUIDANCE. GIVE US A CALL.

Questions? Contact Sam Ross CHITREC Clinical Implementation Manager s-ross@chitrec.org CHITREC info@chitrec.org

Contacts Telligen ILHITREC Linda Brewer Brenda Simms Sr. Quality Improvement Facilitator Meaningful Use Specialist Linda.brewer@area-d.hcqis.org bsimms@niu.edu CHITREC Telligen HITREC Sam Ross Antonio Vega Clinical Implementation Manager HIT Advisor s-ross@chitrec.org avega@telligen.com Telligen Telligen Terrey Currie Sarah Cottington Quality Improvement Facilitator Sr. Quality Improvement Facilitator Terrey.currie@area-d.hcqis.org Sarah.Cottington@area-D.hcqis.org This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-IL-D1-03/15-079