Report shows management of CMS payment program shows vulnerabilities

While CMS has made some progress towards addressing problems with the Quality Payment Program (QPP), a new report shows vulnerabilities remain regarding technical assistance for clinicians and the potential for fraud and improper payments. The HHS Office of the Inspector General (OIG) report noted that if CMS fails to sufficiently address these issues, clinicians may struggle to success under the QPP or choose not to participate. The report also found that CMS needs to put systems in place to effectively prevent, detect, and address fraud and improper payments.

CMS is implementing core provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10) as the QPP, a set of clinician payment reforms designed to put increased focus on the quality and value of care. The QPP is a significant shift in how Medicare calculates payment for clinicians and requires CMS to develop a complex system for measuring, reporting, and scoring the value and quality of care.

Technical assistance

The report shows that if clinicians do not receive sufficient technical assistance, they may struggle to succeed under the QPP or choose not to participate. Clinician feedback collected by CMS demonstrates widespread basic awareness of the QPP, but also indicates uncertainty regarding details of participation such as who must report and how to submit data. CMS contractors have focused largely on general education initiatives, with fewer resources devoted to more customized, practice-specific technical assistance. CMS has established a Service Center to answer questions about the QPP by phone or email. Service Center data indicate that clinicians continue to have questions about both eligibility and scoring criteria, and that small practices, in particular, need information and assistance. Small practices and clinicians in rural or medically underserved areas, who may have fewer administrative resources and less experience with prior CMS quality programs, should be prioritized for assistance. The report stated, “Clinician feedback collected by CMS demonstrates widespread awareness of the QPP, but also uncertainty about eligibility, data submission, and other key elements of the program.”

Fraud

The report also found that if CMS does not develop and implement a comprehensive QPP program integrity plan, the program will be at greater risk of fraud and improper payments. To ensure that the QPP succeeds, CMS must effectively prevent, detect, and address fraud and improper payments. QPP payment adjustments are intended to reward high-value, high-quality care. Safeguarding the validity of Merit-based Incentive Payment System (MIPS) data and the accuracy of QPP payment adjustments is critical to ensure that these payments are based on clinicians’ actual performance. Appropriate oversight is critical to prevent fraud and improper payment adjustments. CMS needs to clearly designate leadership responsibility for QPP program integrity. CMS also needs to develop a comprehensive program-integrity plan for the GPP to ensure the accuracy of MIPS data submitted by clinicians. CMS said that it “is currently in the early stages of developing an oversight plan to QPP data.”

CMS announces Hospice Compare website

CMS released the Hospice Compare website on August 17, 2107. The website allows consumers to make informed decisions about hospice providers based upon the quality of care they provide. Consumers can use the website to find providers in their area and compare them using quality of care metrics.

Reporting

 Hospices are required to report to CMS on several quality measures under Section 1814(i)(5) of the Social Security Act (SSA). The Hospice Quality Reporting Program (HQRP) requires hospice providers to submit data from the Hospice Item Set (HIS) and Hospice Consumer Assessment of Healthcare Providers and Systems (Hospice CAHPS®). The Hospice Compare website compiles data so that consumers can evaluate things like the percentage of patients that were screened for pain or difficulty breathing and whether patients’ preferences were satisfied. The website compiles data from 3,786 hospice providers.

Measures

The Hospice measure set displayed on the website currently includes the following National Quality Forum (NQF) measures from the HIS:

  • Hospice and Palliative Care- Treatment Preferences – NQF #1641
  • Hospice and Palliative Care- Beliefs/Values Addressed- NQF #1647
  • Hospice and Palliative Care- Pain Screening- NQF #1634
  • Hospice and Palliative Care- Pain Assessment- NQF #1637
  • Hospice and Palliative Care- Dyspnea Screening- NQF #1639
  • Hospice and Palliative Care- Dyspnea Treatment- NQF #1638
  • Hospice and Palliative Care- Patients treated with opioids who are given a bowel regimen- NQF #1617

The website will be updated to include the CAHPS data in winter 2018.

AMA provides resources to help physicians with MIPS reporting

As part of its effort to improve Medicare Payment Reform, the American Medical Association (AMA) is providing tools for physicians to better understand and meet the reporting requirements under the new Quality Payment Program from CMS. The AMA has created a “One Patient, One Measure, No Penalty” campaign to help physicians understand the reporting requirements and avoid the 4 percent penalty for not reporting under the Merit-Based Incentive Payment System (MIPS) track. Along with this campaign, the AMA has created an interactive MIPS Action Plan that provides deadlines and a step-by-step plan of how to meet the reporting requirement deadlines.

As part of the “One Patient, One Measure, No Penalty” campaign, the AMA has provided a short video that demonstrates how to fill out CMS forms to accurately report a quality measure on a patient encounter. A step-by-step guide is also provided as a supplement to the video, along with a sample form to review. There are also links to other tools, such as the CMS Quality Measure Search tool, so that all of the resources are available in one easy-to-find location.

The MIPS Action Plan is a ten-step plan that begins with a determination of whether MIPS applies to the physician. The AMA provides a detailed breakdown of some of the determining factors, such as whether a physician is considered a hospital-based physician, in a frequently asked questions supplemental resource. The MIPS Action Plan then proceeds to walk through the process of reporting, including deadlines to start reporting, and submitting 2017 MIPS data.

Kusserow on Compliance: EHR incentive program attestation is serious business

The American Recovery and Reinvestment Act of 2009 (ARRA) (P.L. 111-5) authorized providing incentive payments to eligible health care professionals, hospitals, and Medicare Advantage Organizations (“MAOs”) to promote the adoption and “meaningful use” of health information technology and electronic health record (“EHR”) systems. CMS established the Medicare and Medicaid Electronic Health Record Incentive Programs (EHR Incentive Programs) to make incentive payments to health care professionals and providers that meet specified requirements for the meaningful use of certified EHR technology (CEHRT). The EHR Incentive Programs are intended to bring about improved clinical outcomes and population outcomes, increase transparency and efficiency in health care, empower individuals to make decisions regarding their care, and generate additional research data on health systems. Program participants must report on their performance pertaining to certain clinical quality measures (CQMs) and objectives to CMS (for Medicare) or the authorized state agency (for Medicaid) through an attestation process. Since 2011, the EHR Incentive Programs have made incentive payments to numerous eligible professionals, eligible hospitals, and critical access hospitals (CAHs) that qualify as “meaningful users” by meeting the objectives and CQMs outlined in the various stages of the applicable programs.

Annual attestations required

Eligible providers must annually attest to meeting the specified objectives and measures in order to receive incentive payments under the EHR Incentive Programs. Once they have attested to meeting the identified objectives and measures, they are deemed to be meaningful users and eligible for incentive payments.  CMS, its contractor, and state Medicaid agencies conduct both random and targeted audits to detect inaccuracies in eligibility, reporting, and receipt of payment with respect to the EHR Incentive Programs.  Eligible hospitals may be selected for pre- or post-payment audits. CMS has required that eligible hospitals retain all supporting documentation used in completing the Attestation Module responses in either paper or electronic format for six years post-attestation. Eligible hospitals are responsible for maintaining documentation that fully supports the meaningful use and CQM data submitted during attestation. Those hospitals undergoing pre-payment audits will be required to provide supporting documentation to validate submitted attestation data before receiving payment.

Unsupported and false attestations

Making false statements, including attestations to the federal government, could implicate federal law (18 U.S.C. § 1001), which generally prohibits knowingly and willfully making false or fraudulent statements or concealing information. Although eligible hospitals receiving incentive payments under the Medicare and Medicaid EHR Incentive Programs are not required to follow any particular parameters when spending the payments, they must annually attest to meeting the relevant measures and objectives in order to be entitled to incentive payments. It is critical that eligible hospitals maintain documentation that supports their attestations.  Supporting documentation needs to make clear that the hospital is meeting the terms and conditions of the EHR Incentive Program. A checklist document by itself would be insufficient as supporting documentation. Failure to maintain such supporting documentation creates potential liability. Although no significant enforcement activity has taken place, compliance officers are advised to verify that proper supporting documentation is maintained.  In fact, the responsible program manager should be maintaining documentation as part of ongoing monitoring. As part of ongoing auditing, the compliance office should ensure that monitoring is conducted and validate that it is adequately meeting regulatory requirements.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2017 Strategic Management Services, LLC. Published with permission.