MIPS and Audits Proposed Rule Points to Potential Mega Recoupments

Jim TateBy Jim Tate, EMR Advocate
Meaningful Use Audit Expert
Twitter: @JimTate, eMail: Inquiry@meaningfuluseaudits.com

We are now less than a month away from the CMS Final Rule that will affect Medicare Part B reimbursement far into the future. It is expected that the majority of these providers will fall into the MIPS (as opposed to the Alternate Payment Model) bucket and be subject to the zero sum competitive horse race in which those with high annual composite performance scores will receive incentives that come from what is taken away from the low scorers. That annual score, based on 4 categories (Quality, Advancing Care Information, Clinical Practice Improvement Activities, Resource Use) can mean the difference between going home with a red ribbon or going home with your tail between your legs. Depending on an affected provider’s score, which by the way will be public, the Part B reimbursement could vary +/– 4% for an 8% swing in the early years of the MIPS program. By 2022 that swing could be 18%. However, for providers who score high there is the potential for added incentives so the upside could be even higher. That adds up to a lot of moolah. With the Final Rule now on the horizon we have to hold on a few more weeks and see exactly what the impact of all the public comments will have on what will be written in stone. What is obvious is the potential financial impacts on Part B providers will eclipse anything we have seen in terms of the past Meaningful Use, PQRS, and eRx incentives and penalties.

Since I have been involved in hundreds of audits and appeals related to the CMS EHR Incentive programs it should be no surprise I have an interest in what the Proposed Rule says about audits relative to the MIPS process. Here are a few clarifying comments from CMS that were included in the Proposed Rule:

Will there be audits? Yes, the Proposed Rule outlines a process to “selectively audit MIPS eligible clinicians on a yearly basis”.

What types of documentation will be needed to respond to an audit? According to the Proposed Rule you can expect to “Provide substantive, primary source documents as requested. These documents may include: Copies of claims, medical records for applicable patients, or other resources used in the data calculations for MIPS measures, objectives and activities.”

What happens if data cannot be verified during the audit? “If a MIPS eligible clinician or group is found to have submitted inaccurate data for MIPS, we propose that we would reopen, revise, and recoup any resulting overpayments “.

Will there be any auditing against any entity besides MIPS eligible clinicians? You bet, “any third party intermediary (that is, a QCDR, health IT vendor, qualified registry, or CMS-approved survey vendor) must comply with certain auditing requirements as a condition of their qualification or approval to participate in MIPS as a third party intermediary.”…”Further, we propose the entity must retain all data submitted to CMS for MIPS for a minimum of 10 years.”

I expect the soon to be released Final Rule will be more precise in the description of the MIPS auditing program. However, there are two things I know now. It will all get down to documentation and not being able to provide valid data used to generate a MIPS score will be expensive during an audit. Potentially, much more expensive than a failed Meaningful Use audit. Depending the provider, the recoupment could be hundreds of thousands of dollars.

After the Final Rule hits the airwaves I’ll provide an update in a post titled: MIPS and Audits – Part 2.

Relevant CMS Resources

Proposed Rule: Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models

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: Inquiry@meaningfuluseaudits.com.