Permissible Providers

The types of providers eligible to participate in the Medicare and Medicaid  EHR programs—referred to as permissible providers—differ. Beginning in 2011, the first year of the Medicare and Medicaid EHR  programs, the programs have provided incentive payments to eligible  providers that met program requirements. To receive incentive payments from either the Medicare or Medicaid EHR   To  programs, providers must meet eligibility and reporting requirements.do so, providers report certain information to CMS, the states, or to  both—a process referred to as “attestation”—by entering certain  information into CMS’s or the states’ EHR program web-based attestation  tools. Professionals. For the First Program Year, Processes Are Being Implemented to Verify Requirements Were Met, and CMS Has Opportunities to Improve Them

CMS and the four states we reviewed are implementing processes to  verify whether providers met the Medicare or Medicaid EHR programs’  eligibility and reporting requirements and, therefore, qualified to receive  incentive payments in the programs’ first year. Although CMS is taking  some steps to improve the processes CMS and states use to verify  whether providers have met Medicare and Medicaid EHR program  requirements, we found that CMS has additional opportunities to assess  and improve these processes. CMS and Selected States Are Implementing Processes to Verify Whether Providers Met Requirements to Receive Incentive Payments

For the first program year, CMS is implementing a combination of pre-  and postpayment processes to verify whether providers have met all of  the Medicare EHR program eligibility and reporting requirements. In 2012, according to CMS officials, the agency plans to implement  additional processes to verify, on a postpayment basis, whether a sample  of providers has met all three of the Medicare EHR program’s reporting  requirements. Texas has not yet determined whether it will conduct  additional postpayment verifications. Most Medicare Providers Exempted Themselves from Reporting Certain Measures and Many Reported Others Based on Few Patients

Most providers participating in the first year of the Medicare EHR program  through December 8, 2011, exercised program flexibility to exempt  themselves from reporting on at least one mandatory meaningful use  measure. In addition, many providers also reported at least one clinical  quality measure based on few patients. Clinical quality measures calculated using few  patients may be statistically unreliable, which, according to the American  Hospital Association and others, could detract from providers’ abilities to  use those measures as meaningful tools for quality improvement. CMS has acknowledged that the availability of clinical quality measures  that are relevant to providers’ patient populations and clinical practices is  important to inform providers’ efforts to improve quality of care and to  measure potential impacts of the EHR programs. It is encouraging that CMS has awarded contracts to evaluate states’  implementation of the Medicaid EHR program, including their efforts to  prevent improper payments. Recommendations for Executive Action

In order to improve the efficiency and effectiveness of processes to verify  whether providers meet program requirements for the Medicare and  Medicaid EHR programs, we recommend that the Administrator of CMS  take the following four actions:
Establish time frames for expeditiously implementing an evaluation of  the effectiveness of the agency’s audit strategy for the Medicare EHR  program. HHS disagreed with our fourth recommendation that CMS offer to collect  meaningful use attestations data from Medicaid providers on behalf of the  states, citing two reasons. Despite HHS’s objections, we continue to believe that our  recommendation should be implemented. We are sending copies of this report to the Secretary of Health and  Human Services, the Administrator of CMS, the National Coordinator for  Health Information Technology, and other interested parties. For certain meaningful  use measures, providers may report to CMS that the measures are not  relevant to them; this is referred to as claiming an exemption. Furthermore, to satisfy the requirement for one of the meaningful use  measures “report clinical quality measures to CMS,” providers must report  on clinical quality measures identified by CMS.the number of meaningful use measures and clinical quality measures  providers must report for the first year of the Medicare EHR program.
Why GAO Did This Study

The Health Information Technology for Economic and Clinical Health (HITECH) Act established the Medicare and Medicaid electronic health records (EHR) programs. CMS and the states administer these programs which began in 2011 to promote the meaningful use of EHR technology through incentive payments paid to certain providersthat is, hospitals and health care professionals. Spending for the programs is estimated to total $30 billion from 2011 through 2019. Consistent with the HITECH Act, GAO (1) examined efforts by CMS and the states to verify whether providers qualify to receive EHR incentive payments and (2) examined information reported to CMS by providers to demonstrate meaningful use in the first year of the Medicare EHR program. GAO reviewed applicable statutes, regulations, and guidance; interviewed officials from CMS; interviewed officials from four states, which were judgmentally selected to obtain variation among multiple factors; and analyzed data from CMS and other sources.

What GAO Found

The Centers for Medicare and Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), and the four states GAO reviewed are implementing processes to verify whether providers met the Medicare and Medicaid EHR programs requirements and, therefore, qualified to receive incentive payments in the first year of the EHR programs. To receive such payments, providers must meet both (1) eligibility requirements that specify the types of providers eligible to participate in the programs and (2) reporting requirements that specify the information providers must report to CMS or the states, including measures that demonstrate meaningful use of an EHR system and measures of clinical quality. For the Medicare EHR program, CMS has implemented prepayment processes to verify whether providers have met all of the eligibility requirements and one of the reporting requirements. Beginning in 2012, the agency also has plans to implement a risk-based audit strategy to verify on a postpayment basis that a sample of providers met the remaining reporting requirements. For the Medicaid EHR Program, the four states GAO reviewed have implemented primarily prepayment processes to verify whether providers met all eligibility requirements. To verify the reporting requirement, all four states implemented prepayment processes, postpayment processes, or both. CMS officials stated that the agency intends to evaluate how effectively its Medicare EHR program audit strategy reduces the risk of improper EHR incentive payments, though the agency has not yet established corresponding timelines for doing this work. Such an evaluation could help CMS determine whether it should revise its verification processes by, for example, implementing additional prepayment processes, which GAO has shown may reduce the risk of improper payments. In addition, CMS has opportunities to improve the efficiency of verification processes by, for example, collecting certain data on states behalf.
CMS allows providers to exempt themselves from reporting certain measures if providers report that the measures are not relevant to their patients or practices. Measures calculated based on few patients may be statistically unreliable, which limits their usefulness as tools for quality improvement. CMS and others acknowledged that the availability of measures that are relevant to providers patients and practices and are statistically reliable is important to provide useful information to providers. Among participants in the first year of the Medicare EHR program, the majority of providers chose to exempt themselves from reporting on at least one meaningful use measure and many providers reported at least one clinical quality measure based on fewless than sevenpatients.

What GAO Recommends

GAO is making four recommendations to CMS in order to improve processes to verify whether providers met program requirements for the Medicare and Medicaid EHR programs, including opportunities for efficiencies. HHS agreed with three of GAOs recommendations, but disagreed with the fourth recommendation that CMS offer to collect certain information on states behalf. GAO continues to believe that this action is an important step to yield potential cost savings.