OIG: Flawed procedures for detecting inaccurate MU payments

The Office of the Inspector General (OIG) doubts the Centers for Medicare & Medicaid Services’ (CMS) ability to oversee the Meaningful Use (MU) program and offered recommendations to strengthen the program’s integrity in a November report.

Since CMS began making incentive payments in May 2011, approximately $4 billion has been paid to 82,535 individual providers and 1,474 hospitals. Payments will continue through 2016 and CMS estimates it will spend a total of $6.6 billion. Despite billions spent and more to come, there are gaps in CMS processes for detecting providers inaccurately reporting adherence to MU criteria and safeguards should be strengthened, according to OIG. 

To safeguard against inaccurate payments, CMS conducts automated prepayment validation using the National Level Repository to check self-reported data indicating compliance with MU criteria. CMS also plans to develop a process for identifying risk and conducting postpayment audits, which will require providers to supply documentation supporting self-reported information and return incentives when noncompliance is found. 

OIG investigators determined that these safeguards are not strong enough to prevent making incentive payments to providers that inaccurately report meeting Meaningful Use criteria, according to the report. Prepayment validation “does not verify that self-reported numerators and denominators entered for percentage-based measures reflect the actual number of patients for a given measure or that professionals and hospitals possess certified EHR technology.”

In the case of postpayment audits, OIG investigators questioned whether CMS could rely on the availability of extensive and accurate supporting documentation because requirements that providers maintain records are vague. Additionally, while CMS plans to use reports generated by EHRs to verify self-reported information, EHR certification requirements issued by the Office of the National Coordinator for Health IT don’t completely address this functionality.

“CMS faces obstacles to overseeing the Medicare EHR program that leave the program vulnerable to paying incentives to professionals that do not fully meet the MU requirements,” the report read. “Absent changes to the definition of MU, CMS should consider ways to strengthen its program oversight to protect the $4billion in Medicare EHR incentive payments that it has paid, as well as billions of dollars in future incentive payments.

To strengthen safeguards against inaccurate incentive payments, OIG suggested that CMS and ONC:

• Collect supporting documentation from some providers prior to issuing payment to verify self-reported information;
• Issue guidance detailing requirements for maintaining supporting documentation;
• Adjust criteria for EHR certification to include functionality for producing reports on all MU measures; and
• Improve the certification process to ensure accurate reports.

ONC agreed with all recommendations and CMS agreed with one, but stated that collecting supporting documentation prior to payments would place too much of a burden on providers.

“Our recommendations to CMS focus on immediate changes that CMS can make to improve safeguards, and our recommendations to ONC focus on changes to enhance EHR reports in support of CMS’ oversight activities,” the report concluded. 

The complete report is available from OIG.