Why Medicare may try to recoup $729M in EHR incentive payments

Medicare wrongfully distributed hundreds of millions of dollars in electronic health record (EHR) incentive payments to physicians and other health care professionals over a three-year period, according to an audit by HHS' Office of the Inspector General (OIG) released Wednesday.

The road to the largest public health EHR implementation

Under the 2009 economic stimulus package, eligible professionals and eligible hospitals who demonstrated meaningful use of certified EHRs were able to qualify for Medicaid and Medicare incentive payments.

Audit details

For the audit, OIG reviewed EHR incentive payments CMS made to 250,470 health care professionals from May 2011 to June 2014 to determine whether the agency had made the payments appropriately. The payments totaled $6.09 billion.

Why the EHR life cycle is just like raising a child

OIG selected a random sample from of the payments and examined whether 100 health care professionals who had received one or more incentive payments during the three-year period had submitted the documents required to meet the eligibility criteria for the payments. In addition, OIG reviewed a separate group of payments made to deceased health care professionals, as well as payments made to professionals who switched between Medicare's and Medicaid's EHR incentive programs.

Findings

OIG found that CMS in several instances did not issue EHR incentive payments to health care providers in accordance with federal requirements.

For example, OIG identified 14 cases in which CMS paid health professionals a total of $291,222 in EHR incentives payments even though the professionals did not meet meaningful use requirements because they provided inadequate evidence, inappropriately reported meaningful use periods, and/or did not sufficiently use EHR technology. Overall, OIG estimates that CMS paid a total of $729.42 million in EHR incentive payments to health care professionals who did not meet federal requirements for the payments.

OIG attributed the errors to health care professionals' poor maintenance of data and "minimal documentation reviews" by CMS, which left the program "vulnerable to abuse and misuse of federal funds."

OIG also found that CMS did not issue incentive payments in accordance with program-year requirements for health care professionals who switched between Medicare's and Medicaid's EHR incentive programs. According to OIG, 471 health care professionals who did not meet the appropriate federal requirements received the payments, which totaled $2.34 million. OIG said these errors occurred because CMS did not have a process in place to ensure health care professionals who switched programs were placed in the proper payment years.

Recommendations

OIG recommended that CMS:

• Create a process to allow edits in the National Level Repository system to ensure eligible professionals who switch between Medicare and Medicaid are placed in the correct program year for meaningful use;
• Educate eligible professionals about proper meaningful use documentation requirements;
• Examine a random sample of eligible professionals' documentation regarding meaningful use attestation for program years not reviewed in the audit to try to identify whether any payment errors were made;
• Review the incentive payments it paid for each of the payment years reviewed in the audit to identify any professionals who did not actually qualify for the payments and attempt to recover those payments;
• Try to recover the $291,222 in inappropriate incentive payments the agency made to the 14 health care professionals identified in OIG's audit who did not meet meaningful use requirements; and
• Try to recover the $2.3 million in overpayments it made to eligible professionals who switched between Medicare's and Medicaid's EHR incentive programs.

In addition, OIG recommended that, as CMS implements MACRA's new meaningful use requirements, the agency allow for consistent verification of data reported by health care professionals. OIG said such a change would ensure eligible professionals are using EHR technology as intended under the incentive program.

CMS' response

CMS said it plans to take action on four of OIG's recommendations, including trying to recover the hundreds of millions of dollars the agency inappropriately distributed and educating health care professionals about appropriate documentation requirements.

In addition, CMS said it has implemented targeted risk-based audits to improve the incentive program's integrity and expects to continue the audits in 2017.

CMS officials in a statement said it "is committed to turning the page and ushering in a new era of accountability." The agency continued, "Providing high-quality care to Medicare beneficiaries while being responsible stewards of taxpayer dollars remains a top CMS priority, and we recognize the value data validation and auditing bring to our programs" (Evans, Wall Street Journal, 6/12; HHS OIG audit, 6/7; HHS OIG release, 6/7).

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