Your Bridge to Health IT. Successfully Navigating MU Audits. July 18, 2017

Your Bridge to Health IT Successfully Navigating MU Audits July 18, 2017 1

Illinois Health Information Technology Regional Extension Center (ILHITREC) SUPPORT PROVIDED BY ILHITREC: ILHITREC is under contract with the Illinois Department of Health and Family Services (HFS), to provide education, outreach and support to Medicaid providers for the Electronic Health Record Medical Incentive Payment Program (emipp). ILHITREC partners with the Illinois Critical Access Hospital Network (ICAHN) and Central Illinois Health Information Exchange (CIHIE) for support in this mission and collaborates with the Chicago Health Information Technology Regional Extension Center based at Northwestern University which serves the City of Chicago. 2

Speaker Biographies Brenda Simms, RN, BSN, CHTS-CP, CMAP Brenda Simms is a Clinical Informatics Specialist at ILHITREC. She works with physicians, practice managers, clinical staff, billing representatives, physicians and EHR vendors to successfully plan, coordinate and implement an electronic health record (EHR) system, as well as assist practices with workflow redesign and development of required quality reporting. Brenda also worked for a time with the Central Illinois Health Information Exchange (CIHIE) to facilitate the implementation and effective adoption of HIE. 3

Discuss the Audit Process LEARNING OBJECTIVES Discuss steps to take in preparing for an audit Discuss what to expect during an audit 4

You Cannot Escape The Responsibility Of Tomorrow By Evading It Today." Abraham Lincoln The time to prepare for an audit is before you receive the letter. 5

HISTORICAL SUMMARY The Electronic Health Record Medicaid Incentive Payment Program was implemented through the American Recovery and Reinvestment Act of 2009 (ARRA) Incentive Payments for the 2 tier program are: Medicare = $44,000 over five years; Last year for payment is attestation year 2016 Medicaid = $63,750 over six years; Last year for payment is attestation year 2021 Last year to begin participation was attestation year 2016 HITECH Act provided assistance to participating providers in the form of Regional Extension Centers (REC) 2 RECs in Illinois ILHITREC provides services to eligible providers for Illinois outside the City of Chicago CHITREC provides services to eligible providers for 606 area code 6

AUDITS EHR Incentive Program Medicaid Audits will be conducted by: Department of Healthcare and Family Services Office of the Inspector General, Bureau of Medicaid Integrity EHR Incentive Programs Medicare Audits will be conducted by: Figliozzi & Company http://www.figliozzi.com/faqs.htm OIG Audit of a State s Medicaid EHR Incentive Program Who is Subject to an Audit? Any eligible provider (EP) Any eligible hospital (EH) Any eligible critical access hospital (CAH) Attesting to and receiving an EHR incentive payment through the Illinois Medicaid EHR Incentive program Types of Audits: Pre-Payment Audit Post-Payment Audit 7

BE PREPARED FOR AN AUDIT Maintain Your Audit Trail: The Audit Trail should, read like a story, start at the beginning: Provider Eligibility Information CEHRT Qualifying Information Program Story Year, Stage and the Reporting Period Meaningful Use Objective Clinical Quality Measures Measure Documentation for the Attestation Year General Important Information: Two People (minimum) should know where the audit file is located and have access to it They should be well versed in Meaningful Use, organization workflows and how you achieved the measures Should be able to answer questions about the EHR Incentive Program They should know attestation process The information should be readily available Don t dig for the information if Auditor performs an onsite 8

IF YOU ARE SELECTED FOR AN AUDIT Pre and Post Payment Audit Selection Patient Volume in Illinois is considered a Pre-Payment Audit (100%) 10% Random Audit Based on Risk Profiles Providers may be selected only 1 year or multiple years Notification of an Audit The audit notification is by email, but you may receive a letter Notification will go to the email on file for the Provider Audit letters should have the official logo of the entity that will be conducting the audit, either Figliozzi (CMS Logo) or HFS/OIG Logo. 30 Calendar Day Response Time Respond Quickly May request an extension from the Auditor Missing Deadlines or Failure to Respond may cause an unfavorable outcome! The audit may be conducted either through email or on-site or both A demonstration may be requested by an on site Auditor Be Prepared Auditor (s) are there to review a certain year, but if they uncover other issues of concern, they have carte blanch to review other matters. 9

RESPONSIBILITY FOR PREPARING FOR AN AUDIT It is the responsibility of the eligible entity receiving the incentive payment to maintain proper documentation Documentation supporting the attestation should be kept for six years (6) post attestation Paper and electronic format be maintained Block out all protected health information (Follow the instructions on the audit notice) Demonstrate that results can not be or have not been manipulated, by saving in a version such as PDF. Be prepared to produce other documentation as requested The Audit notification will go to the email on file for the provider You have 30 Calendar Days to respond to this request You may request an extension Be precise in the reason for requesting an extension 10

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P a g e 1 2 3 Office of Inspector General Illinois Department of Healthcare and Family Services 2200 Churchill Rd, Bldg A-1 Springfield, Illinois 62702 www.state.il.us/agency/oig Bruce Rauner Governor Bradley K. Hart Inspector General Date of Audit Letter Name Address City, Il Zip Notice of Review Provider Name Provider NPI Dear Provider, This notice is to inform you that your Medicaid EHR Incentive Program application for program year 2014 has been selected for a post payment audit. It is the goal and mandate of the program to minimize fraud, waste, and abuse, and your cooperation will be greatly appreciated in this endeavor. We hope to work as partners with you and your staff to ensure the integrity of the program in the most efficient manner. Please read the following documentation request carefully. We request that you provide this documentation within thirty calendar days of this notice. If you are unable to complete the request, please e-mail us requesting an extension as soon as possible. All providers selected for audit will need to send the following information via secure e-mail, certified mail or upload the information directly into the application software: A copy of the purchase agreement contract with the vendor from whom the Certified E.H.R. Technology was purchased A signed attestation letter regarding audit documentation (See Attached)

P a g e 1 3 3 Report of total encounters from all sites included in the 90-day reporting period attested to in the application. To accelerate the audit process, the report should include: Payer (Medicaid, private health insurance etc.,) MCO information (if applicable) Billing and Rendering NPI Place of Service Code (if applicable) Patient Name Date of Service Patient Date of Birth (MM/DD/YYYY) For FQHC/RHC providers only: Reports that verify each of the "needy individual" population included in the registration. Needy individuals include: Sliding Fee scale encounters Charity care encounters Children's Health Insurance Program (CHIP) encounters If the attestation provider is a Physician Assistant (PA), provide administrative documents (invoices, organizational charts, staff meeting minutes, etc.,) demonstrating the PA role in the facility If during the program year the eligible professional attested to Meaningful Use (MU), please submit all reports used to populate the state level emipp application for the various attested MU measures Audits will be rated either satisfactory or unsatisfactory. Please be advised that an audit may be ruled unsatisfactory for reasons including, but not limited to: incompleteness of information, failure to comply with deadlines, or gross discrepancies between the documentation and the attested data. Any unsatisfactory audit may lead to penalties up to and including full recovery of the incentive payment. You will have the opportunity to appeal any unsatisfactory audit by using the Requests and Appeals function within the EHR module. Your cooperation throughout this process is greatly appreciated. If you have questions or need any additional information, please contact HFS.OIG.Audit@Illinois.gov. Thank you, Office of the Inspector General Illinois Department of Healthcare and Family Services Medicaid EHR Incentive Program

P a g e 1 4 3 ATTESTATION OF SUPPORTING DOCUMENTS I hereby attest that all of the documentation that I/my facility have uploaded to the emipp system, mailed, emailed or faxed to the Illinois Department of Healthcare and Family Services Office of the Inspector General is, to the best of my knowledge, complete, accurate, and unabridged. I furthermore acknowledge that all providers and/or facilities are fully aware an unsatisfactory audit may result in penalties up to and including full repayment of the incentive payment received, for which each individual provider and/or facility is responsible. I also acknowledge any provider has the right to appeal an unsatisfactory audit by using the Requests and Appeals function with the emipp system. Provider/Facility Director's/Supervisor's Name (printed) Director's/Supervisor's Signature Date

SUGGESTED DOCUMENTATION Disclaimer: Utilization of this document does not guarantee that the Eligible Entity will pass a CMS or State of Illinois Audit 15

NON-PERCENTAGE MEANINGFUL USE DOCUMENTATION Objective Threshold Requirement Suggested Documentation Meaningful Use Dashboard Numerators and Denominators Generated from CEHRT Referred to by CMS as Source Documentation Actual Meaningful Use Report Clearly identifying: Reporting Period Eligible Entity Name with NPI Date Report was generated/printed Documentation to support any Exclusions taken Patient Lists (Stage 1) How list was generated/purpose CEHRT Appropriate for Year of Attestation Page from CPHL/CMS Certification ID Number Vendor Documentation List of Type of Clinical Lab Tests Incorporated Screen Shot of report prior to running the report Screen Shots Prior/During Reporting Period Show Clinical Decision Support (CDS) rules enabled dated prior to reporting period Drug/Drug; Drug/Allergy and Drug Formulary Enabled Name of Formulary Vendor Screen Shot of report prior to running the report Hospital Payment Calculation Documents supporting Cost Reports Hospital calculation worksheet 16

NON-PERCENTAGE MEANINGFUL USE DOCUMENTATION Objective Threshold Requirement Suggested Documentation HIPPA Security Risk Analysis (SRA) Physical Inspection Report Report documenting procedures performed during analysis, evidence it was generated for provider s system identified by: CMS Certification ID (CCN) Provider Name Practice Name, TIN, etc. List of security deficiencies/mitigation plan/updates Standards followed when conducting SRA How Encryption/security of data at rest addressed (Stage 2) Remember Printers and Fax machines have hard drives, how do you protect PHI? Registry Reporting: 1. Immunization Registry 2. Syndromic Surveillance Reporting 3. Specialized Registry 4. Electronic Reportable Lab Reporting (Hospitals/CAHs Only) Active Engagement Date screenshots from EHR Dated record of successful electronic submission Letter or email public health agency or registry confirming successful transmission including date of submission, sending and receiving party Exclusions Alternate Exclusions Documentation to support each exclusion to a measure claimed by the provider Document to support exclusion Reports from CEHRT system showing denominators of zero Public Health Letter documenting provider unable to submit and would qualify for exclusion CMS will not require documentation that provider did not intent or plan to attest to menu objective to claim 17 alternate exclusion

Objective Eligibility Requirements ELIGIBILITY DOCUMENTATION Threshold Requirement Support Eligibility Suggested Documentation List of Eligible Providers or Facility with NPI, CMS ID# Tax ID Number (TIN) Group Definitions with list of group members Locations Physician Assistant Hardship Exemption Single or Multiple PA Lead Year Filed List of all locations in which EP encounters occurred Documentation FQHC or RHC is PA Lead if PA requesting eligibility Copy of the Application and any supporting documentation submitted Patient Volume Requirements EHR System Minimum 30% Medicaid 20% Pediatrician Purchased for AIU In place for MU Reports that support calculations of Medicaid and total patient encounter volumes, explanation of how and when they were generated Table 4 of UDS Report for FQHC (s) Documentation to prove Acquisition examples: Contract documents Documents supporting Invoice Documents supporting Purchase Order Lease documents License documents Hospital Payment Calculation Documents supporting Cost Reports Hospital calculation worksheet 18

SUGGESTED DOCUMENTATION MEANINGFUL OBJECTIVES Utilizing 2017 Meaningful Objectives as the Example 19

MEANINGFUL USE OBJECTIVES DOCUMENTATION Objective Threshold Requirement Suggested Documentation Patient Electronic Access Provide Patient Access View,Download,Transmit (VDT) >50% At Least 1 Patient Sample of a Clinical Summary (de-identified) Define how and when given to patient Pertinent Policy and Procedures Public Health Reporting Immunization Reporting Syndromic Surveillance Reporting Specialized Registry Reporting Electronic Reportable Lab Resulting Reporting Public Health Reporting to 3 Registries Exclusions Do Not Count as Meeting Measure Actual Email to Public Health to verify engagement Documentation to show level of Engagement with Registry: Options for Engagement: 1. Completed Registration to Submit Data Must be completed 60 days after starting reporting period 2. Completed Testing and Validation 3. Production 4. https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Centraliz edrepository-.html Additional Suggestions Objectives Clinical Quality Measures 1. Objective/CQM Documentation from CMS listing 2. Specs for that Criteria 3. Any FAQs from CMS that were used to interpret questions 20

EH/CAH MEANINGFUL USE OBJECTIVES DOCUMENTATION Objective Threshold Requirement Suggested Documentation Protect Patient Health Information Yes/No Attestation Physical Inspection Report List of Security deficiencies and action plan how they are mitigated (Review/Updated) Electronic Prescribing >50% Screen Shots of Drug/Drug and Drug/Allergy functionality enabled during entire reporting period Screen Shots or Documentation verifies drug formulary was enabled, dated prior to the beginning of the reporting period and during entire reporting period Name of Formulary Vendor (ex: Superscripts) Health Information Exchange >10% Example of Summary of Care (De-identified) List of sharing partners Policy/Procedure of how and when exchanged Documentation to support exchange of key clinical info Patient Specific Education >10% Policy/Procedure of how Patient Education is distributed Source of Patient Education (commercial/designed) Medication Reconciliation >50% Policy and Procedure and/or workflow for Med Rec21

DOCUMENTS TO UPLOAD WITH ATTESTATIONS 22

DOCUMENTATION TO SUBMIT WITH ATTESTATION Mecky Lang: Contact Method: hfs.ehrincentive@illinois.gov There could be more than 1 reason attestation is rejected Read Your Letter After An Attestation is Submitted, Documents May be Uploaded in the emipp Tracking Mode Objective Screen Requirement Upload Documentation Patient Volume FQHC/RHC Only FQHC Eligibility Screen in emipp Upload the patient volume reports used: 1. Shows the 90 day reporting period (Summary, etc.) 2. Report used to determine volume 3. Report-Total Encounters from all sites for 90 reporting period: 1. Payer 2. Medicaid Managed Care Information (If applicable) 3. Billing and Rendering NPI 4. Place of Service (If applicable) 5. Patient Name 6. Date of Service 7. Patient Date of Birth (MM/DD/YYYY) 4. Report to Verify Needy Individuals 1. Sliding Fee Scale Encounters 2. Charity Care Encounters 3. Children s Health Insurance Program (CHIP) encounters **** Table 4 of UDS Report Uploaded Submission w/o Rejected Physician Assistant (PA) Attestation Eligibility Screen in emipp 1. Administrative Documents Demonstrating the PA Role in the Facility: 1. Invoices 2. Organizational Charts 23 3. Staff Meeting Minutes

DOCUMENTATION TO SUBMIT WITH ATTESTATION Mecky Lang: Contact Method: hfs.ehrincentive@illinois.gov There could be more than 1 reason attestation is rejected Read Your Letter After An Attestation is Submitted, Documents May be Uploaded in the emipp Tracking Mode Objective Screen Requirement Upload Documentation Attestation Year for AIU Eligibility Screen in emipp 1. Documentation supporting Certified EHR: 1. Lease 2. Contract 3. Purchase Order 4. Training Invoice Attestation to Meaningful Use Public Health Reporting Meaningful Use Tab CQM Tab Public Health Reporting Tab 1. Actual Meaningful Use Dashboard Report/Date Run from CEHRT System 2. Shows Reporting Period 3. Provider Name/NPI 4. Actual Numerators and Denominators for MU and CQMs 5. Documentation to Support Yes or No attestations Actual Email to Public Health to verify engagement Documentation to show level of Engagement with Registry: Option of Engagement 1-4 on slide #16 Proof of Specialized Registries 24

SCREEN SHOT EXAMPLES Clinical Decision Support DRUG ALLERGY CHECK 25

MU ATTESTATION SUMMARY REPORT GENERATED BY emipps 26

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Responding To An Audit 28

Audit Information Email Questions: HFS.OIG.Audit@Illinois.gov Sending information to OIG - Preferred methods are: Upload documents either in the audit tab or regular upload documents tab State file transfer portal Available at this link: (https://filet.illinois.gov/filet/pimupload.asp ). Secure email 29

emipp Audit Tab 30

Audit Results = No Adverse Findings 31

emipp Audit Tab - Comments 32

emipp Audit Tab - Documents 33

emipp Audit Tab- Example of Uploaded Documents 34

If I Have Already Attested, Can I Upload Documents? Yes, You Can Upload Documents Through the Tracking Mode 35

WHAT HAPPENS IF I FAIL AN AUDIT? APPEAL PROCESS If the Provider fails the audit There is one (1) appeal opportunity Make it Count Respond quickly and be precise in your rebuttal UNSATSIFACTORY AUDIT RESULTS What Happens if a Provider Fails an Audit after Appeal? The payment will be recouped from the provider or the entity receiving payment if the provider does not meet requirement criteria The payment for all years may be required to be re-paid under certain circumstances 36

WHAT HAPPENS IF I FAIL THE AUDIT One opportunity to appeal Make it Count Audits will be rated either Satisfactory or Unsatisfactory Audits Ruled Unsatisfactory for reasons including but not limited to: Incompleteness of Information Failure to Comply with Deadlines Gross Discrepancies between the documentation and the attested data Eligible entity may be required to repay the incentive payment for failure to meet requirements Eligible entity may be required to repay all years of incentive payment if requirements for the year being audited or fraud is detected The intent of the Auditor is to review the designated attestation year if something else is uncovered, the Auditor may investigate whatever he or she determines is necessary 37

OIG HER Incentive Program Audit Information https://www.illinois.gov/hfs/sitecollectiondocuments/ehrincentiveprogramaudits.pdf 38

HFS ILLINOIS MEDICAID TOOLKIT https://www.illinois.gov/hfs/medicalproviders/emipp/pages/default.aspx Most Current Version Audit Information Page 57+ Read Appendix A and B BE PREPARED You may be asked for additional documentation. 39

AUDIT REFERENCES Official CMS EHR Incentive Website: https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/ Audit Information: https://www.illinois.gov/hfs/sitecollectiondocuments/ehrincentiveprogramaudits.pdf Illinois EHR Incentive Program Tool Kit (Version 8.2, March 27, 2017): Audits page 43-44 https://www.illinois.gov/hfs/sitecollectiondocuments/2016ehrincentiveprogramtoolkit.pdf CMS = https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/AppealsAudits_2015through2017 SupportDoc.pdf https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/AppealsAudits_EHRAppealsOver view-.pdf Certified Health IT Product List https://chpl.healthit.gov/#/search 40

Questions? Contact Information: Brenda Simms bsimms@niu.edu Kerri Lanum klanum@niu.edu Emily Fricker efricker@niu.edu General www.ilhitrec.org info@ilhitrec.org (815) 753-5900 41