Audits mostly random, some chosen through red flags

Need to know documentation to have on hand for a meaningful use audit and who's likely to be audited? Here's the latest from CMS's Elizabeth Holland.

Elizabeth Holland, director of the Health Information Technology Initiatives Group for the Office of E-Health Standards & Services, sat down with SearchHealthIT to discuss the rollout of meaningful use audits, which will be conducted on a selected group of providers, regardless of whether they are earning incentives from Medicare, Medicaid or both. Some providers will receive audits before they're paid; others, after. This is part one of the interview. Part two is here.

There have been people who got the audit letter and sent back their check.

Elizabeth Holland,
CMS

The big question on the mind of every meaningful use eligible provider (EP) and eligible hospital (EH): How does the Centers Medicaid and Medicare Services (CMS) select those who will be audited?

Elizabeth Holland: Well, we're really doing two things. We're doing post-pay audits that we started doing in mid-2012, and we've just started pre-pay audits. Some of the selections are being made totally randomly, and other selections are based on protocols that identify things that look suspicious.

For example, if there's a whole practice and everyone has the exact same scores on everything, or there were some that we looked at where everyone got 100% on every [meaningful use] measure. Just things like that where we would say, 'Hmm, is this really true?'

So some will be picked by chance, but others because of red flags?

Holland: Yes. We are targeting 5% to 10% of providers who are getting payments.

Walk us through the audit process. We get a letter that we're going to be audited, and then what?

Holland: It's really a give-and-take sort of situation. You get a letter saying, 'This is the documentation we want from you.' I think they give [providers] two weeks, initially, to give them the documentation. If there's an issue, they just need to call the auditor and tell them, 'Two weeks is not going to work; I need time.'

The reason for the two weeks is for the pre-pay audit. We have such a quick timeframe because we're holding them up from payment, and unless they give us the documentation that we need to review, they're never going to get moved into the payment flow.

So you get the letter, you give the documentation, and sometimes that's fine. You don't need to do anything else. We look at the documentation, everything checks out and you're good to go. Other times, there's much more of a back and forth [with auditors needing additional documentation]. If there's issues that the provider thinks the documentation is sufficient, but the auditor doesn't, [the auditors] come back to my staff and we talk about whether we think it's sufficient or not.

A lot of decisions are being made on a case-by-case basis. We're trying to be as flexible as we possibly can. That's why we put out some of the guidance; because it seemed that people were confused about what they needed to have. We're trying to be much more open about what is appropriate to keep in case you are audited.

I will say, there have been people who got the audit letter and sent back their check.

They just knew they wouldn't pass the audit?

Holland: Or they didn't have an EHR at all; I don't know what the reason is. There have been a few of those. But a huge majority of the people have passed the audit just fine.

If I'm an EP or EH that has been red-flagged, is that noted in the letter?

Holland: You wouldn't know if you were a red flag or a random.

Are there any differences between a pre-pay and post-pay audit?

Holland: They're really the same thing, but we try to work with the pre-payment audit people more quickly, but if you go on a slower timeline -- if you can't get your documentation back -- that just means your payment will be more delayed.

How do the Medicare, Medicaid and dual-eligible audits differ, or are they harmonized to be the same?

Holland: The dual-eligible and Medicare hospitals are the same, because the same contractor [Figliozzi and Company] is doing them. And all the Medicare EPs are the same. Medicaid EPs do their own thing because the states run that, and Medicaid-only hospitals, the states would do also. They could vary somewhat, but the vast majority of hospitals -- all the duals -- Medicare is doing.

Let us know what you think about the story; email Don Fluckinger, news director, or contact @DonFluckinger on Twitter.

This was first published in April 2013

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