Mis­taken EHR in­cen­tive pay­ments may have been un­avoid­able

Modern Healthcare - - TECHNOLOGY - By Rachel Z. Arndt

Af­ter HHS’ Of­fice of In­spec­tor Gen­eral an­nounced that the CMS po­ten­tially made mis­taken pay­ments to providers for mean­ing­ful use, health­care pol­icy ad­vis­ers ques­tioned the agency’s over­sight ca­pa­bil­i­ties. But some won­dered whether the over­pay­ments, which to­taled an es­ti­mated 12% of in­cen­tive pay­ments, may have just been the price of do­ing busi­ness.

“Twelve per­cent sounds pretty alarm­ing,” said Jeff Smith, vice pres­i­dent of pub­lic pol­icy for the Amer­i­can Med­i­cal In­for­mat­ics As­so­ci­a­tion, “but I would imag­ine that it’s prob­a­bly within one or two stan­dard de­vi­a­tions of the mean for other CMS pro­grams.” He cited a 2015 Gov­ern­ment Ac­count­abil­ity Of­fice re­port es­ti­mat­ing that fraud, waste and abuse made up more than 10% of Medi­care’s bud­get.

Be­tween May 2011 and June 2014, the CMS paid providers an es­ti­mated $729.4 mil­lion in in­cen­tive pay­ments that shouldn’t have been dis­trib­uted, the OIG said. The money went to providers who had EHRs that pu­ta­tively met fed­eral stan­dards. But, it turns out, ac­cord­ing to the OIG, some of those providers didn’t meet mean­ing­ful-use cri­te­ria through the use of cer­ti­fied EHRs. They ei­ther failed to sup­port self-re­ported in­for­ma­tion, failed to re­port mean­ing­ful-use pe­ri­ods, or im­prop­erly used the EHRs. Those mis­takes led to pay­ments that shouldn’t have ever gone out.

“This kind of thing hap­pens in new pro­grams,” said for­mer CMS head Gail Wilen­sky of the over­pay­ments. “When it hap­pens, you want to get it fixed, and if it con­tin­ues to hap­pen, that’s more dis­turb­ing than hav­ing sur­faced it early in its ex­is­tence.”

“Twelve per­cent sounds pretty alarm­ing, but I would imag­ine that it’s prob­a­bly within one or two stan­dard de­vi­a­tions of the mean for other CMS pro­grams.” Jeff Smith Vice pres­i­dent of pub­lic pol­icy Amer­i­can Med­i­cal In­for­mat­ics As­so­ci­a­tion

One so­lu­tion could be bet­ter au­dits, Wilen­sky said. “There’s no rea­son the CMS can’t do spot au­dits,” she said.

But those aren’t work­ing, ac­cord­ing to the OIG, which found “tar­geted riskbased au­dits are not cap­tur­ing er­rors” iden­ti­fied in the re­port. As such, the OIG rec­om­mends that the CMS fig­ure out which providers didn’t meet mean­ing­ful-use cri­te­ria and try to re­cover the over­paid money. The agency can do so, the OIG said, by look­ing over its in­cen­tive pay­ments and re­view­ing a ran­dom sam­ple of providers’ doc­u­men­ta­tion.

Some mean­ing­ful-use cri­te­ria are par­tic­u­larly bur­den­some to ver­ify, Smith said, es­pe­cially for small prac­tices that don’t have ded­i­cated staff for mean­ing­ful use. Take, for in­stance, the re­quire­ment for EHRs to have clin­i­cal de­ci­sion-sup­port ca­pa­bil­i­ties, in­clud­ing alerts. EHRs must be able to do this through­out the re­port­ing pe­riod. As such, should the CMS re­quire a daily screen­shot of an alert? “Self-at­tes­ta­tion is more or less the only op­tion you have,” Smith said.

Other mean­ing­ful-use re­quire­ments are un­clear, said Claire Mi­ley, a health­care at­tor­ney with Bass Berry and Sims. “There was a lot of con­fu­sion when the reg­u­la­tions first came out about the stan­dards,” she said, which may have led to prob­lems in self-at­tes­ta­tion.

In the fu­ture, the CMS could con­sider build­ing com­pli­ance tests into the pol­icy it­self, Smith said. But right now, the ten­dency is to de­velop poli­cies first and fig­ure out com­pli­ance later, he said.

As such, it might be wise, for in­stance, to take pay­ment mis­takes into ac­count in its bud­get cal­cu­la­tions, Smith said, much as credit card com­pa­nies do.

Be­yond the money, though, is pa­tient safety, which is neg­a­tively af­fected by providers who don’t meet mean­ing­ful-use re­quire­ments with their EHRs, said Wil­liam Marella, ex­ec­u­tive di­rec­tor of pa­tient safety or­ga­ni­za­tion op­er­a­tions and an­a­lyt­ics for the ECRI In­sti­tute. “If there are providers who were not ac­tu­ally us­ing the EHR in the way the mean­ing­ful-use cri­te­ria would dic­tate, there could po­ten­tially not be ben­e­fits to qual­ity and safety,” he said.

It’s tough to say how broad the ef­fects are, Marella said, since “you can’t tell from this re­port whether they ac­tu­ally didn’t meet mean­ing­ful use cri­te­ria or whether they just couldn’t prove it.”


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