Here’s what you need to know in order to survive an audit.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaced the Medicare Sustainable Growth Rate (SGR), which was how CMS previously controlled the cost of Medicare Payments to physicians. MACRA is aimed at strengthening Medicare access, improving physician payments, and encouraging better patient care among other improvements. Under MACRA, CMS is required to implement a Quality Payment Program (QPP), which offers clinicians and practices two separate tracks: (1) the Merit-Based Incentive Payment System (MIPS) track; and, (2) the Advanced Alternative Payment Model (Advanced APM) track. Both tracks can result in penalties for not meeting certain requirements/benchmarks or incentives for meeting and exceeding requirements/benchmarks.
As with any federal program, CMS has the authority to audit the reported data and the underlying source documentation. If these audits uncover evidence of false claims, fraud or abuse, CMS and the Inspector General can levy fines (treble damages) or even bar providers from participation in the Medicare program. The threshold of materiality is one cent.
If your practice is selected for audit, your practice has 45 calendar days to respond to the CMS request for data. Occasionally, CMS may agree upon an alternate time-frame, but be prepared for a 45-day deadline. You should expect to provide copies of claims and/or medical records for applicable patients as well as any other supplemental documentation used to support your MIPS measures and activities.
Using an external organization such as ReportingMD) to submit your data on your behalf will not preclude your participation in the audit process. External organizations (for example, registries, health IT vendors, survey vendors etc.) are also required to comply with auditing policies and procedures as a condition of program qualification and acceptance. It is very important for all organizations participating in or supporting participants in the Medicare program to retain all records and accounts according to policy and to provide any requested documentation to CMS upon request.
How much documentation should you keep?
To be in accordance with the False Claims Act, you should keep documentation up to six years and CMS may request any records or data retained for MIPS purposes for up to six years. This was finalized in the CY 2019 Quality Payment Program final rule. This documentation is for all the MIPS performance categories excluding Cost, since no data is submitted for the MIPS Cost category.
What type of documentation should you have on hand for the other three categories?
- Quality: Supporting documentation for the data submitted to CMS or a third party intermediary should be retained. If you submitted less than the six required measures, less than the full measure set, or no outcomes/high priority measures then you will need data documentation to validate whether you submitted all applicable MIPS measures and encounters using claims and registry data.
- Promoting Interoperability: Documentation to support your submission should be retained.
- Improvement Activities: Documentation used to validate the activities should be retained and those documents should demonstrate consistent and meaningful engagement within the time period for which you attest to. CMS provides recommended documentation for each improvement activity.
To avoid failing an audit, be prepared. Institute a step-by-step audit response process by determining which stakeholders need to be assembled and create an outline with accountabilities, owners, and detailed response steps; conduct a mock audit by developing a tactic for audit notification receipt. Ensure your audit response process is fully loaded and use lessons learned from the internal mock audit to refine your process.
The criteria which determine MIPS eligibility are multi-faceted and complex. ReportingMD understands these criteria and works with client organizations to optimize incentive performance in the MIPS (and other value-based care programs.)
With the proven experience of our client services team and Total Outcomes Management (TOM™) a powerful measure calculation engine, ReportingMD can help you navigate the complexities of the MIPS program.
We were invited by CMS to help develop the MIPS program, which provides our team with unique expertise and a depth of experience that’s unmatched.
Using TOM™, practices can gain operational visibility to the quality performance of their physicians and avoid CMS penalties for non-compliance. TOM™ aggregates data from multiple sources to identify and manage patient care gaps.
Learn why mid to large sized healthcare organizations turn to ReportingMD for powerful tools that help improve patient care, improve quality outcomes, and maximize reimbursements.