What you need to know about pre- and post-payment EHR audits

By David Nilasena, M.D.
Chief Medical Officer for the Centers for Medicare and Medicaid Services’ Southwest Region

An eligible professional, eligible hospital, or critical access hospital that attests to receive an incentive payment for either the Medicare or Medicaid electronic health record incentive program may be subject to an audit.

CMS and its contractor, Figliozzi and Co., will conduct audits on Medicare and dually-eligible (Medicare and Medicaid) providers who are participating in the EHR incentive programs. Medicaid providers participating in the Medicaid EHR incentive program will be subject to audits by the states and their contractors.

Pre- and post-payment audits

CMS began pre-payment audits this year, starting with attestations submitted during and after January 2013. The pre-payment audits don’t replace pre-payment edit checks that have already been built into the EHR incentive programs’ systems to detect inaccuracies in eligibility, reporting, and payment.

Pre-payment audits are random and may target suspicious or anomalous data. Providers selected for pre-payment audits will have to present supporting documentation to validate their attestation data before CMS releases their incentive payment.

CMS, through its contractor, will also conduct post-payment audits during the course of the EHR incentive programs. Providers selected for post-payment audits will be required to show supporting documentation to validate their submitted attestation data.

Preparing for an audit

To be prepared for a potential audit, providers should have on hand electronic or paper documentation that supports their attestation. If they are selected for an audit, providers will also need to produce documentation that supports the values they entered in the attestation module for clinical quality measures. Hospitals should also maintain documentation that supports their payment calculations. For more guidance on what documentation to retain for audits, see the “Supporting Document for Audits” fact sheet found at www.cms.gov/Regulations-
and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EHR_SupportingDocumentation_Audits.pdf.

Audit results

Providers found ineligible for an EHR incentive payment based on their pre-payment audit will not receive payment. In the case of post-payment audits, the payment will be recouped when a provider isn’t found to be eligible. CMS may also pursue additional measures against providers who attest fraudulently to receive an EHR incentive payment.

Providers found ineligible for their incentive payment will also face a payment adjustment beginning in 2015. Providers should always accurately report and properly document to avoid payment penalties.

Audit materials

Additional audit materials can be found on the educational resources page of the CMS EHR incentive programs website under the title “Audit Information and Guidance” found at www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/EducationalMaterials.html.