Meaningful Use Audits: An Update

By Jim Tate, EMR Advocate
Meaningful Use Audit Expert
Twitter: @JimTate, eMail:

The lion’s share of the CMS EHR incentives have been paid out, especially for those who participated on the Medicare side of the incentive program. The Meaningful Use (MU) incentives are winding down but it is prudent to keep an eye on the rear view mirror and make sure you are up to date on past MU documentation. One of the more common questions we are asked at Meaningful Use Audits has to do with how long after attestation can a CMS Meaningful Use audit take place. What is the look back period? How long does an Eligible Professional (EP) or Eligible Hospital (EH) need to keep their “book of evidence” in a handy place? When it is OK to breathe easy?

Our friends at CMS tell us: “Eligible professionals (EPs), eligible hospitals (EHs), and critical access hospitals (CAHs) should retain ALL relevant supporting documentation (in either paper or electronic format) used in the completion of the Attestation Module responses. Documentation to support attestation data for meaningful use objectives and clinical quality measures should be retained for six years post-attestation.”

So six years post-attestation is the period in which an incentive recipient needs to be prepared to respond to an audit. What are the chances you might be audited for an early attestation, say back in 2011 or 2012? I’m not a gambler and have never been too good at calculating odds but I was recently contacted by an EP who had received an audit engagement letter from the gang over at Figliozzi & Company. That EP had never been audited before and received the letter just a few week ago in early September 2015. The audit was for a 2011 attestation. That’s right, the audit was going all the way back to the 2011 attestation. There was scant guidance and clarification from CMS in those early days of MU and I imagine an EH or EPs “book of evidence” could be a bit on the slim side.

I don’t need to tell you what the lesson is here. An occasional glance in the rearview mirror to make sure documentation is intact would not be a bad thing to do.

Jim Tate is known as the most experienced authority on the CMS Meaningful Use (MU) audit and appeal process. His unique combination of skills has brought successful outcomes to hospitals at risk of having their CMS EHR incentives recouped. He led the first appeal challenge in the nation for a client hospital that had received a negative audit determination. That appeal was decided in favor of the hospital. He has also been successful in leading the effort to reverse a failed appeal, even after the hospital had received notification of the failure with the statement, “This decision is final and not subject to further appeal”. That “final” decision was reversed in less than a week. If you are a hospital with questions or concerns about the meaningful use audit process, contact him at: This post was original published on