The Hospital Readmissions Reduction Program is a CMS pay-for-performance program that links the amount hospitals are paid to risk-adjusted readmission rates. Measures included in the program are claims based, which simply means that the ICD-10 codes we submit on our claims for payment are also used to assess our performance; our performance then impacts our payment.
Prevention is better than a cure. In the world of HIPAA privacy and security, training and awareness are among the most important aspects of prevention. The best laid policies and procedures won't keep your patient's PHI safe if no one knows how or why to follow them. But effective and engaging training methods can be elusive. Employees and administrators might begin to treat their annual training as routine, going through the motions to get their certificate, and then falling victim to a phishing attack that could have been avoided. New hires may be overwhelmed by the scope of HIPAA?it's a huge law?or struggle to connect it to their job duties. Developing education and awareness strategies that capture employees' attention and build privacy and security into the culture of their workplace can be a tall order.
CMS giveth and CMS taketh away. More than $21 billion in payments under the Medicare EHR Incentive Program and more than $10.1 billion in Medicaid EHR Incentive Program payments has been doled out between 2011 and 2015?but not every payment remains with its intended recipient. Contractors will perform audits to ensure that those eligible for the program can support their attestation through examination of supporting documentation to back a claim that a provider or hospital has fulfilled the requirements for meaningful use.
CMS contracted Figliozzi and Company to conduct pre- and postpayment desk audits of the meaningful use program.
"What we have been seeing from our clients' experience is Figliozzi is attempting to perform audits on 5% of attestations submitted to CMS," says David Holtzman, JD, CIPP, vice president of compliance at CynergisTek, Inc., in Austin, Texas.
Holtzman also notes a spike in state Medicaid offices and the Office of Inspector General (OIG) performing audits for those attesting to meaningful use. These audits are conducted on site by a team of auditors.
"Both Medicaid and Medicare meaningful use audits are pass-fail audits," Holtzman says. "Therefore, if any requirement or measure is not met, the result is that the provider or hospital will not receive the incentive payment in the case of a prospective audit or will be required to return any payment received for the prior period as a result of the audit."
Under the Affordable Care Act, the latter would be considered an overpayment by Medicare or Medicaid, and the provider or organization would be required to return the incentive dollars within 60 days or face fines and penalties subject to the False Claims Act.
"There is increased attention by the U.S. Attorney's Office and the Office of Inspector General for investigating and prosecuting fraudulent attestations for meaningful use that results in incentive payments," Holtzman says. "I look at this as a claims recovery effort."
CMS may occasionally report on overall rates of audit failure by eligible providers and hospitals. However, it will not provide any specific guidance on how to resolve identified issues, Holtzman says. "Once the reporting year has ended, the attestation is filed or the hospital/provider selected for audit, no substantive changes are permitted," he says. "Best practices are to carefully review documentation for meaningful use attestation using internal experts or bring in a third-party reviewer to ensure accuracy."
Security officers may sometimes feel that they're asked to do too much with too little. Limitations surrounding staffing, budgets, or resources, or an administration that simply doesn't understand the importance of information security, can make a difficult task even more complicated. In some organizations, information security is a relatively new department and might lack the connections and relationships that more well-established departments rely on for support. Security needs allies. Fortunately, there's one they may already work closely with who is ideally suited: internal auditors.
On November 16, 2015, CMS released a final rule that bundles acute-care payments for knee and hip replacement surgeries, the most common type of inpatient surgeries for Medicare beneficiaries, with some 400,000 performed in 2004.
When the Quality Improvement Organizations (QIO) took over the role of education and enforcement for the 2-midnight rule on October 1, 2015, many anticipated that their reviews would only look at records from that date forward. But in an unpleasant turn of events, some hospitals have reported QIO records requests zeroing in on cases as far back as May 2015.
