Incorrect EHR Incentive Payments Top $720 Million, Audit Finds

CMS criticized for lax oversight

From May 2011 through June 2014, the Centers for Medicare and Medicaid Services (CMS) paid an estimated $729 million in Medicare electronic health record (EHR) incentive payments to eligible professionals (EPs) who did not comply with federal requirements, according to an audit conducted by the Department of Heath and Human Services Office of Inspector General (OIG). In addition, the CMS paid $2.3 million in inappropriate EHR incentive payments to EPs who switched incentive programs.

In April 2015, Congress enacted the Medicare Access and Children’s Health Insurance Program [CHIP] Reauthorization Act (MACRA). Among other changes, MACRA established payment reforms that consolidated several programs into a Merit-Based Incentive Payment System (MIPS), including the Medicare EHR Incentive Program for EPs (now known as Advancing Care Information under MIPS). In November 2016, the CMS issued a final rule implementing the reforms in MACRA. The changes under the Advancing Care Information element of MIPS replaced the EHR incentive programs and revised the way Medicare EPs receive payments for being “meaningful users.”

The OIG’s review covered EHR incentive payments totaling approximately $6.1 billion that Medicare made to 250,470 EPs from May 2011 to June 2014 (the audit period). The OIG selected a random sample of 100 EPs who received one or more payments during the audit period and reviewed the support for their attestations to meaningful-use measures. In addition, the OIG reviewed all payments made to deceased EPs and to EPs who switched between Medicare and Medicaid programs to determine whether Medicare made inappropriate payments during the audit period.

The OIG found that the CMS did not always make EHR incentive payments to EPs in accordance with federal requirements. In the sample of 100 EPs, the OIG identified 14 with payments totaling $291,222 who did not meet meaningful-use requirements because of insufficient attestation support, inappropriate reported meaningful-use periods, or insufficiently used EHR technology. On the basis of these results, the OIG estimated that the CMS inappropriately paid $729,424,395 in incentive payments to EPs who did not meet meaningful-use requirements.

These errors occurred because sampled EPs did not maintain support for their attestations, the audit notes. Furthermore, the CMS conducted minimal documentation reviews of self-attestations, leaving the EHR program vulnerable to abuse and misuse of federal funds.

The CMS also made EHR incentive payments that were not in accordance with the program-year payment requirements when EPs switched between Medicare and Medicaid incentive programs. Specifically, the OIG identified 471 EHR incentive payments totaling approximately $2.4 million that the CMS made to EPs for the wrong payment year. These errors occurred because the CMS did not have edits in place to ensure that EPs who switched from one program to the other were placed in the correct payment year upon switching.

The OIG recommended that the CMS:

  • Recover $291,222 in payments made to the sampled EPs who did not meet meaningful-use requirements
  • Review EP incentive payments to determine which EPs did not meet meaningful- use measures for each applicable program year to attempt recovery of the $729,424,395 in estimated inappropriate incentive payments
  • Review a random sample of EPs’ documentation supporting their self-attestations to identify inappropriate incentive payments that may have been made after the audit period
  • Educate EPs on proper documentation requirements
  • Recover $2,344,680 in overpayments made to EPs after they switched programs
  • Employ edits to ensure that an EP does not receive payments under both EHR incentive programs for the same program year

Source: HHS Audit; June 2017.