AHLA. G. Meaningful Use Stage 3 Coming, Stages 1 and 2 Compliance

Transcription

1 AHLA G. Meaningful Use Stage 3 Coming, Stages 1 and 2 Compliance Samantha Burch Vice President of Health and IT Federation of American Hospitals Washington, DC James F. Flynn Bricker & Eckler LLP Columbus, OH Elizabeth S. Holland Director, HIT Initiatives Group Office of E-Health Standards and Services Center for Medicare and Medicaid Services Windsor Mill, MD Institute on Medicare and Medicaid Payment Issues March 25-27, 2015

2 Meaningful Use Stage 3 Coming, Stages 1 and 2 Compliance Presented by Samantha Burch Vice President, Legislation & Health IT Federation of American Hospitals Washington, DC James F. Flynn, Esq. Bricker & Eckler LLP Columbus, OH Elizabeth S. Holland, MPA Director, Health Information Technology Center for Clinical Standards and Quality, CMS Baltimore, MD March 2015 Agenda Background and Overview CMS Perspective Industry Perspective Audit and Appeal Tips and Pointers Q& A 2 1

3 Where is all of this headed? ONC leading and collaborating with health IT and health care sector shared roadmap for achieving interoperable health IT that supports a broad scale learning health system by 2024 Draft version 1.0 issued February, 2015; seeking comments and hope to finalize later in Background Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of American Recovery and Reinvestment Act of 2009 Meaningful use is defined as demonstrating that certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination. 42 USC 1395ww(n)(3)(A)(ii) 42 USC 1395w-4(o)(4) 2

4 Certified EHR Technology (CEHRT) Certified EHR Technology = technology that meets certification criteria established by the Office of National Coordinator (interoperability) 2011 criteria 2014 criteria CEHRT Flexibility Rule (9/1/14) If unable to fully implement 2014 CEHRT due to delays in availability of technology upgrades 2015 (October, 2014 for hospitals) = must use 2014 CEHRT MU Regulations 42 C.F.R : Meaningful use objectives and measures for EPs, eligible hospitals and CAHs Stage 1 Final Rule July 28, 2010 (75 Fed. Reg ) = MU criteria beg Stage 2 Final Rule Sept. 4, 2012 (77 Fed. Reg ) = MU criteria beg Stage 3 Proposed Rule still waiting MU criteria beg (Oct for hospitals) 3

5 Stage 1 MU Stage 1 Meaningful Use EHs 14 core criteria and 5 of 10 menu criteria EPs 15 core criteria and 5 of 10 menu criteria After two years, must move to Stage 2 BUT Early adopters (2011) = 3 years AND Those who got to Stage 2 by 2014 can remain at Stage 2 for 3 years through 2016 If Stage 1 in 2013 or 2014, note changes Stage 2 MU Stage 2 Meaningful Use EHs 16 core criteria and 3 of menu criteria EPs 17 core criteria and 3 of 6 menu criteria After two years, must move to Stage 3 BUT Stage 2 = 3 years if started in 2014 Most differences = increased percentage of use Some menu criteria now core criteria Some core criteria eliminated or incorporated into 2014 EHR technology criteria 4

6 Helpful resources Stage 1 and Stage 2 MU Criteria tip sheets CMS Stage 1 vs. Stage 2 Comparison Tables For Hospitals (Appendix 1 to MMI outline) For Physicians/EPs (Appendix 2 to MMI outline) Summary of Stage 1 and Stage 2 objectives and measures with differences noted (Appendix 3 to MMI outline) MU Counting Rules Unique patients (42 CFR 495.6(c)) Considering only those patients whose records are maintained using CEHRT (i.e., sufficient data was entered in the CEHRT to allow the record to be saved and not rejected for incomplete data) Denominator and numerator counts In all other cases, use all patient records in numerator and denominator 5

7 MU Counting Rules Hospitals counting Emergency Department admits Either of two methods permitted; must select one and apply consistently to all measures Observation Services method: All patients admitted to inpatient (POS 21) either directly or through the ED All patients initially presenting to ED (POS 23) and receive observation status (including POS 22) All ED visits (POS 23 only) but include all actions taken for such patients in ED and i/p Incentive payments for: Eligibility Eligible hospitals = acute care hospitals, critical access hospitals (CAHs), children s hospitals and cancer hospitals ( subsection (d) hospitals ) Eligible professionals (EPs) = MDs, DOs, dental medicine or surgery, chiropractors, podiatrists and optometrists (but not hospital-based EPs 90%+ services in hospital or ER) For Medicaid, EPs also include nurse practitioners, certified nurse midwives, and physician assistants who work for FQHC or RHC led by PA Medicare Advantage organizations for certain affiliated EPs and eligible hospitals 6

8 Medicare and Medicaid Program Participation Medicaid must meet minimum volume requirements (10% for hospital; 30% for EPs other than pediatricians at 20%) EPs can only receive incentive payments from EITHER Medicare or Medicaid, not both; before 2015, can switch one time Hospitals can get payments from both Medicare and Medicaid Payments Incentive Payment Amounts - EPs Medicare = up to $44,000 over 5 years Medicaid = up to $63,750 over 6 years 10% add-on if more than 50% of services in HPSA Incentive Payment Amounts Critical Access Hospitals Reimbursement of reasonable costs associated with depreciable assets in a single payment year rather than depreciated over the useful lives of assets 7

9 Payments Incentive Payment Amounts Hospitals $2,000,000 + ($200 per discharge for 1,150 th 23,000 th discharges) x (Medicare Share) x (Transition Factor) Medicare Share = (# of Medicare and MA inpatient days) / (Total inpatient days x [(Total charges-charity care charges) / Total charges)] Transition Factor = 100% - year 1 75% - year 2 (year 1 if 2014 first MU year) 50% - year 3 (year 1 if 2015 first MU year) 25% - year 4 Reporting Periods Reporting Periods Hospitals = federal fiscal year basis (i.e., Oct. 1 Sept. 30) Physicians/EPs = calendar year basis Reporting period for first year of any stage = 90 days Reporting period for subsequent years = entire year Special for 2014: all reporting periods = 90 days Special for 2015??? 8

10 Attestation of MU Attestations On-line submission (user guide available) Core measures (must satisfy all) Menu measures (must satisfy minimum number) Clinical quality measures (required by CMS) Due within 60 days after end of reporting period Hospitals = November 30; Physicians/EPs = February 28 Recent extensions: Hospitals = December 31; Physicians/EPs = March 20 Medicare only Year to Year MU Transition Factors Payment for adopting by FY % 75% 50% 25% Payment for adopting in FY % 75% 50% 25% Payment for adopting in FY % 75% 50% 25% Payment for adopting in FY % 50% 25% Payment for adopting in FY % 25% 9

11 Year to Year MU Consecutive versus skipping years Medicare standard: must continually meet the meaningful use criteria in order to receive incentive payment in any year Even if do not receive payment in one year, eligible for future years But must still be on schedule Medicaid standard: NOT required to continually meet; can skip years and pick up where they left off E.g., first year = stage 1; second year = skip; third year = stage 1 Exclusions and Exceptions Exclusions certain exclusions from objectives and measures may be applicable Hospitals without sufficient internet access New hospitals and new EPs EPs who lack face-to-face or telemedicine interactions EPs who practice at multiple locations and lack control over use of CEHRT for 50% or more of their patient encounters Hardship exceptions case-by-case application Due 6 months prior to applicable payment adjustment E.g., April 1, 2015 for 2016 payment adjustment based on 2014 MU 10

12 Medicare & Medicaid EHR Incentive Programs Elizabeth S. Holland, MPA Director, Health Information Technology Center for Clinical Standards and Quality, CMS January 2015 Medicare Incentive Payments January 2015 Providers Paid January 2015 Payment Amount Program to Date Providers Paid Program to Date Payment Amount Eligible Professionals Doctors of Medicine or Osteopathy 11,073 $ 97,703, ,758 $ 6,282,095,719 Dentists 8 $ 78, $ 5,474,799 Optometrists 382 $ 3,451,929 22,995 $ 276,462,924 Podiatrists 302 $ 2,331,420 17,906 $ 239,718,383 Chiropractors 557 $ 5,167,496 16,254 $ 172,452,670 Total Eligible Professionals 12,322 $ 108,733, ,384 $ 6,976,204,495 Eligible Hospitals Subsection (d) Hospitals 688 $ 635,977,904 $ 8,460 $ 11,796,275,069 Critical Access Hospitals 62 $ 18,076,917 $ 2,000 $ 791,040,278 Total Hospitals 750 $ 654,054,821 $ 10,460 $ 12,587,315,347 TOTAL 13,072 $ 762,787, ,844 $ 19,563,519,841 11

13 Medicaid Program Totals January 2015 AIU Program to Date MU Program to Date Total Program to Date Providers Payment Providers Payment Providers Payment Physicians 93,313 $ 1,953,144,945 55,867 $ 484,041, ,180 $ 2,437,186,698 Nurse Practitioners 24,575 $ 521,463,931 11,940 $ 106,884,674 36,515 $ 628,348,605 Dentists 14,127 $ 300,016,834 1,013 $ 8,920,750 15,140 $ 308,937,584 Certified Nurse Midwives 2,711 $ 57,587,500 1,716 $ 15,644,250 4,427 $ 73,231,750 Optometrists 83 $ 1,756, $ 263, $ 2,020,167 Physicians Assistants practicing in FQHC or RHC led by a PA 1,614 $ 34,170, $ 7,650,000 2,494 $ 41,820,000 Eligible Professionals Total 136,423 $ 2,868,139,877 71,438 $ 623,404, ,861 $ 3,491,544,804 Acute Care Hospitals (including CAHs) 3,483 $ 2,717,252,873 5,614 $ 2,572,584,852 9,097 $ 5,289,837,725 Children's Hospitals 81 $ 186,403, $ 128,242, $ 314,646,435 Medicare Advantage Hospitals 1 $ 505,931 $ 1 $ 505,931 Eligible Hospitals Total 3,565 $ 2,904,162,796 5,702 $ 2,700,827,295 9,267 $ 5,604,990,091 Grand Total 139,988 $ 5,772,302,673 77,140 $ 3,324,232, ,128 $ 9,096,534,894 Program Payments thru January 2015 Amount Paid 2011 Program Year Amount Paid 2012 Program Year Amount Paid 2013 Program Year Amount Paid 2014 Program Year Amount Paid 2015 Program Year Amount Paid Program To Date Medicare Eligible Professionals $ 979,666,454 $ 2,879,790,933 $ 2,575,693,027 $ 541,054,080 $ $ 6,976,204,495 Doctors of Medicine or Osteopathy $ 869,606,164 $ 2,606,127,832 $ 2,317,169,243 $ 489,192,480 $ $ 6,282,095,719 Dentists $ 757,738 $ 2,256,298 $ 2,041,322 $ 419,440 $ $ 5,474,799 Optometrists $ 39,019,045 $ 116,937,152 $ 105,218,728 $ 15,288,000 $ $ 276,462,924 Podiatrists $ 51,783,860 $ 97,193,161 $ 75,523,922 $ 15,217,440 $ $ 239,718,383 Chiropractors $ 18,499,648 $ 57,276,490 $ 75,739,812 $ 20,936,720 $ $ 172,452,670 Medicaid Eligible Professionals $ 1,048,787,200 $ 1,197,669,278 $ 1,059,931,697 $ 185,092,878 $ 63,750 $ 3,491,544,804 Certified Nurse Midwives $ 23,545,000 $ 24,076,250 $ 22,134,000 $ 3,476,500 $ $ 73,231,750 Dentists $ 56,057,500 $ 109,861,084 $ 107,969,250 $ 35,007,250 $ 42,500 $ 308,937,584 Nurse Practitioners $ 172,309,173 $ 198,438,420 $ 215,044,342 $ 42,535,420 $ 21,250 $ 628,348,605 Optometrists $ $ 8,500 $ 1,204,167 $ 807,500 $ $ 2,020,167 Physicians $ 783,360,527 $ 852,352,275 $ 700,791,688 $ 100,682,208 $ $ 2,437,186,698 Physicians Assistants $ 13,515,000 $ 12,932,750 $ 12,788,250 $ 2,584,000 $ $ 41,820,000 Eligible Hospitals & CAHs $ 3,178,959,355 $ 5,583,260,866 $ 6,254,411,386 $3,173,901,625 $ 1,772,204 $ 18,192,305,437 Medicare Only $ 113,430,824 $ 231,421,666 $ 229,659,211 $ 128,077,130 $ $ 702,588,831 Medicaid Only $ 129,581,442 $ 107,540,952 $ 116,192,294 $ 25,284,341 $ 1,594,619 $ 380,193,649 Medicare/Medicaid $ 2,935,947,089 $ 5,244,298,248 $ 5,908,559,881 $3,020,540,154 $ 177,586 $ 17,109,522,958 Medicare Advantage Organizations For Eligible Professionals $ 180,106,590 $ 134,773,289 $ 91,873,828 $ $ $ 406,753,707 Total $ 5,387,519,599 $ 9,795,494,367 $ 9,981,909,938 $3,900,048,584 $ 1,835,954 $ 29,066,808,

14 Unique Providers Paid thru January 2015 Unique Providers Paid 2011 Program Year Unique Providers Paid 2012 Program Year Unique Providers Paid 2013 Program Year Unique Providers Paid 2014 Program Year Unique Providers Paid Program To Date Medicare Eligible Professionals 58, , ,418 58, ,783 Doctors of Medicine or Osteopathy 51, , ,291 52, ,188 Dentists Optometrists 2,576 8,593 10,219 1,604 12,344 Podiatrists 2,916 6,275 6,886 1,826 8,744 Chiropractors 1,452 4,844 7,815 2,142 9,245 Medicaid Eligible Professionals 49,942 68,738 76,092 13, ,767 Certified Nurse Midwives 1,108 1,422 1, ,802 Dentists 2,643 5,290 5,488 1,717 14,150 Nurse Practitioners 8,120 11,264 14,378 2,752 25,020 Optometrists Physicians 37,430 49,981 53,609 8,160 92,068 Physicians Assistants ,626 Eligible Hospitals & CAHs 2,320 3,307 4,215 3,335 4,765 Medicare Only Medicaid Only Medicare/Medicaid 2,195 3,071 3,896 3,148 4,388 Medicare Advantage Organizations For Eligible Professionals 10,472 11,315 11,641 13,635 Total 121, , ,366 74, , Audit basics Any provider that successfully demonstrated meaningful use for either EHR Incentive Program may be subject to an audit CMS, and its contractor, Figliozzi and Company, will perform audits on Medicare and dually-eligible (Medicare and Medicaid) providers who are participating in the EHR Incentive Programs States, and their contractor, will perform audits on Medicaid providers participating in the Medicaid EHR Incentive Program 26 13

15 Medicare audits Medicare EPs and Dual-Eligible Hospitals Pre- and post-payment audits are performed 5-10% of providers subject to pre/post-payment audits Random audits and risk profile of suspicious/anomalous data If a provider continues to exhibit suspicious/anomalous data, could be subject to successive audits In order to ensure robust oversight, CMS will not be making the risk profile public 27 Medicare Audits The audit notification includes the initial request list The provider has 4 weeks to respond to the initial request The notification also includes the specific auditor at Figliozzi and Company CPAs that has been assigned to the audit Please respond to this auditor upon receipt of the audit notification and confirm who will be the contact person at the provider s office for the audit. If a provider is selected for an audit, they will receive an from meaningfuluse@figliozzi.com So that audit notifications are not sent to spam, the provider should add to the figliozzi.com domain to their whitelist or trusted sites

16 Medicare documentation It is the provider s responsibility to maintain documentation Documentation to support attestation data for meaningful use objectives and CQMs should be retained for six years post-attestation Save any electronic or paper documentation that supports attestation, including documentation that supports values you entered in the Attestation Module for CQMs Hospitals should also maintain documentation that supports their payment calculations Medicaid providers can contact their State Medicaid Agency for more information about audits for Medicaid EHR Incentive Program payments 29 Audit determinations Before a final determination is made there is a follow up request letting the provider s contact person know what items are still needed in order to achieve a successful audit and more importantly meaningful use. An additional 2 weeks are afforded to the provider to furnish additional supporting documentation. A final request is sent if items are still outstanding and the provider is given 2 more weeks to support the attestation with auditable documentation. Shortly thereafter an audit determination is made and the provider receives an with the audit determination letter

17 Appeals Providers have the option to appeal an adverse audit decision and in order to start the appeal process, they must submit the appropriate appeals filing form found at: Guidance/Legislation/EHRIncentivePrograms/Appeals. html Failure to submit the appeal form within 30 days from the date of this letter will forfeit the option to appeal. 31 Stage 1 results - EPs Top three most failed measures: Protect Electronic Health Information (y/n) Clinical summaries Access to Certified Electronic Health Record Technology 32 16

18 Stage 2 results - EPs Top three most failed measures: Generate lists of patients (y/n) Protect Electronic Health Information (y/n) Use secure messaging (5%) 33 Stage 3 Give providers additional flexibility, Make the program simpler and reduce burden, Drive interoperability among electronic health records, Increase the focus on patient outcomes to improve care

19 Rulemaking Intent Announcement On Jan. 29, CMS announced its intent to engage in rulemaking this spring CMS is considering the following changes: o Shortening 2015 reporting period to 90 days o Realigning hospital reporting to calendar year o Modifying other aspects of programs to match goals, reduce complexity, lessen reporting burden See Dr. Conway s blog on 35 Medicare Payment Adjustments Demonstrate meaningful use (2014 for 2016) Apply for a hardship (deadline April 1, 2015 for eligible hospitals; deadline July 1, 2015 for eligible professionals) Notification is sent is providers, then reconsideration period 36 18

20 2015 EP Payment Adjustments Payment Adjustment Amount EPs PERCENT $1 $250 87,000 34% $250 $1,000 55,000 21% $1,000 $2,000 36,000 14% $2, ,000 31% N=256,000 EPs currently subject to 2015 payment adjustments 37 Meaningful Use: Attestations, raudits & Appeals AHLA MMI March,

21 Payment Adjustment IPPS Hospitals Medicare payment adjustment for IPPS hospitals that are not meaningful users of certified EHR technology Begins in FY 2015 Applied to ¾ of the hospital update (not for CAHs) Reduced by 25% in FY15, 50% in FY16 & 75% in FY17 (and beyond) Two year look back: Payment Adjustment Year Full Year EHR Reporting Period Hospitals that first demonstrate MU in FY 2014 had to complete a 90 day reporting period in the first 9 months of 2014 to avoid a penalty in 2015 (April 1 deadline) Payment Adjustment CAH Hospitals Reduction in reasonable cost reimbursement in FY15 & subsequent years From current 101% to % in FY15, % in FY16 & 100% in FY2017 (and beyond) Reporting period aligned with payment adjustment year Required to submit Meaningful Use attestations by Nov. 30 of following FY 40 20

22 Payment Adjustment Medicare EPs Medicare Payment Adjustment: Applicable percent of the fee schedule that would otherwise apply. Statute defines applicable percent as: For 2015, 99% (98% if subject to erx adjustment) For 2016, 98% For 2017 (and beyond), 97% Statute provides that if, for CY18 (and beyond), the Secretary finds that less than 75% of EPs are meaningful users, the applicable percent can be decreased by an additional 1% from the preceding year (but not less than 95%) EP not subject to e-rx adjustment in 2014 EP subject to e- RX adjustment in % 98% 97% 96% 95% 95% 98% 98% 97% 96% 95% 95% 41 Audit Experience & Lessons Learned 42 21

23 43 Hospital Audit Experience Medicare Then: Extensive back and forth on documentation requests Hospitals feeling their way through with auditors Now: Later adopters have had easier time Audits have become more standardized Focus still largely on proving hospital has and can run reports Figliozzi viewed as very reasonable (especially compared to States) Clinical/HIT knowledge of auditors still viewed as low Occasional disconnects between documentation requests and vendor requirements (e.g., logs) Hospital Audit Experience Medicare Continued Proving version of certified EHR technology getting harder with growing number of vendor products Examples of Figliozzi working through issues, especially when hospital is pro active Perception that audits aren t really random Hospitals generally cautious about asking for extensions Generally high success rate Perception that Stage 2 audits will be more difficult 44 22

24 Hospital Audit Experience Medicaid Far less satisfaction with audit experience State variation continues both in terms of substance and sophistication of auditors Big focus on security risk assessment (especially EP side) Opportunity for States to dig into IT infrastructure? Focus on vendor contracts New contracts vs. ongoing services causing issues In general, asking for documentation beyond Figliozzi (e.g., patient level detail for quality measures) Perception of auditing to audit and overreaching Duplicative documentation requests 45 Lessons Learned from 2013 Still Relevant Important to: Have your own calculations you can back up Human error exists on all sides Work with the auditors to clarify and confirm documentation requests Is what I think they re asking for really what they re asking for? Have a process in place for maintaining and uploading documentation Don t be afraid to ask! Auditors have generally shown they want to work with providers

25 Lessons Learned 2014 Experience leading hospitals to: Be pro active with Figliozzi in establishing the foundation for why you re doing what you re e.g., providing regulatory language or FAQ Helpful to get documentation from your vendor 3 rd party credibility to prove version of CEHRT Version Certified HIT Products List (CHPL) # Date installed In large health systems, easiest to centralize audit responsibility 47 More on Audits and Appeals James F. Flynn, Esq. Bricker & Eckler LLP Columbus, OH March,

26 Audit issues Documentation to support attestation of satisfying criteria electronic or paper form Examples Criteria of criteria Stage 1 Measure and measures: Stage 2 Measure Use computerized provider order entry (CPOE) for medication orders directly entered by authorized health care professionals More than 30% of all Unique patients with at least one medication ordered with CPOE More than 60% medication orders by CPOE; more than 30% lab orders by CPOE; more than 30% radiology orders by CPOE Audit issues (cont d.) Criteria Stage 1 Measure Stage 2 Measure Implement drug drug and drug allergy interaction checks Maintain an up to date problem list of current and active diagnoses Record patient demographic information (e.g., preferred language, gender, race, date of birth, etc.) YES/NO More than 80% of all unique patients have at least one entry or indication of problems More than 50% of all Unique patients seen have demographics recorded as structured data YES/NO Not a Stage 2 criterion More than 80% of all Unique patients seen have demographics recorded as structured data 25

27 Audit issues (cont d.) Types of documentation: Screenshots from the certified EHR system Reports generated by the certified EHR system Report should show CEHRT used Should link to CEHRT attestation Should be dated during attestation period Denominator records existing record systems (paper or electronic) Yes/No Functionality verifications Other Audit Preparation Possible Audit Preparation Steps: Develop policies and practices for documenting electronic activities (e.g., screenshots) Get the right personnel involved, engaged Clinical (CMO, CMIO?) Technology Attestation / Financial Record-keeping and documentation 26

28 Audit Preparation (cont d.) Possible Audit Preparation Steps (cont d.): Certified EHR Technology compliance Complete understanding of each of the applicable Stage 1 (including 2013 and 2014 changes) and Stage 2 MU criteria, objectives and measures Attestation compliance verification process Treat errors and remediation efforts same or similar way as overpayments Record retention 6 years Appeals Critical access hospitals can appeal cost reimbursement discrepancies through cost report appeals (PRRB) Hospitals can appeal payment calculation and reconciliation discrepancies through cost report appeals CMS determinations follow informal process within CMS to exhaust administrative remedies for: Failed audits (pre-payment or post-payment) Failed reporting of meaningful use due to EHR technology Clinical Quality Measures e-reporting disputes Eligibility Other 27

29 Appeals (cont d.) Statutes preclude certain actions from administrative or judicial review: Methodology and standards for determining a hospital-based eligible professional Specification of reporting periods and the selection of the form of payment For hospitals, making estimates or using proxies of discharges and inpatient bed days, hospital charges, charity charges or Medicare share Methodology and standards for determining payment amounts and payment adjustments Appeals (cont d.) Statutes preclude certain actions from administrative or judicial review (cont d.): Methodology and standards for determining a meaningful EHR user including: Selection of Quality Measures The means for demonstrating meaningful use (e.g., attestation, claims submission, etc.) Hardship exception Interest on demands for recoupment, interest accrues at over 10% (42 C.F.R ) 28

30 Appeals (cont d.) Stage 2 proposed rule proposed appeal procedures, but not adopted in final rules: We recognize that there is a procedural appeals process currently in effect, and in all cases, we will require that requests for appeals, all filings, and all supporting documentation and data be submitted through a mechanism and in a manner specified by us. We expect all providers to exhaust this administrative review process prior to seeking review in Federal Court. (Cite: 77 Fed. Reg ) Seek judicial review of adverse determinations OIG Audits of State Medicaid EHR OIG Work Plan State audit reports Florida = correct Louisiana and Massachusetts = incorrect Other state audits ongoing (e.g., Texas, Ohio) 29