GAO: CMS verification of providers in incentive program lacking

The Centers for Medicare & Medicaid Services has implemented some procedures to verify whether providers have met the eligibility and reporting requirements of the electronic health record incentive program, but needs to do more, according to a new report published by the Government Accountability Office (GAO).

The GAO, analyzing what measures have been instituted to check whether providers met the requirements, noted that CMS has implemented automatic checks built into its databases to verify information submitted by providers when they register and whether they're using a certified EHR system, as required by the program.

CMS is also developing its strategy to audit providers post payment. According to the report, starting in 2012, CMS plans to audit a sample of 10 percent of eligible professionals and 5 percent of hospitals to see if they meet the reporting requirements. The agency also will audit 20 percent of eligible professionals and 10 percent of hospitals to verify that they're really using certified EHRs, and is developing processes to verify that payments made to hospitals are accurate.

However, the GAO found that these processes were insufficient.

"As a new program with particular complexities--such as the number and types of measures providers must report--there are risks to program integrity, and CMS could take steps, beyond those already taken, to assess and mitigate the risk of improper payments and to improve program efficiency," the GAO stated.

The GAO appeared particularly concerned about auditing providers before they're paid incentive money so as to avoid the "pay-and-chase" method of dealing with improper payments, an issue CMS has been struggling with. CMS has been trying to move away from "pay and chase" when dealing with fraudulent payments as well in its recovery audit contractor program.

The GAO recommended, among other things, that CMS establish time frames for evaluating the effectiveness of its audit strategy, consider conducting more verification on a prepayment basis and offer states the option of having CMS collect attestations from Medicaid providers on behalf of the states. CMS disagreed with the latter recommendation.

To learn more:
- read the report (.pdf)
- here's more on CMS' effort to reduce 'pay and chase' in fighting improper payments
- here's the status of prepayment review in the RAC program