Just as the Meaningful Use (MU) EHR Incentive program brought potential audits to providers, so it will be with the MIPS program. Both programs were enacted by Federal legislation, and while there are differences, they are also similarities.
The MU program contained EHR incentives for both Medicare and Medicaid defined providers. For Medicare eligible providers (EP) there was a sole CMS contractor responsible for all audits and appeals. The Medicaid audits and appeals were handled at the state level by a number of different entities. If an EP failed an audit, and it was truly a pass/fail system, the received incentive was recouped for the year under audit. Audits were conducted only against a specific EP for a specific year. The funds recouped involved no penalties, only the received incentive amount. I estimate that perhaps one-third of MU audits were failed and according to CMS the number one cause of a failed audit was the lack of an acceptable Security Risk Analysis.
The MIPS audit program is in its infancy but there are significant differences from those reviews we saw under the MU program. Since the program is focused on Medicare Part B reimbursement, there will be a consistent national process with no state level audits. MIPS eligible clinicians receive an annual MIPS score of 0 – 100. The audits would not bring a pass/fail decision but a possible recalculation of a specific year’s MIPS score. As it is possible to submit MIPS data as either an individual or as a group, the audits would likely follow the same course.
I believe an audit that finds inaccurate or missing documentation will cause a recoupment of funds based on a recalculation of the MIPS score. For the purposes of simplicity let’s take an extreme example: an audit is initiated against a year with a 9% +/- potential reimbursement adjustment. If an initial submission earned a +9% positive adjustment for $250,000 in Medicare Part B reimbursement, that would be an additional $22,500. If an audit was made, and no documentation was provided to document any portion of the MIPS score, a negative reimbursement of up to $22,500 would ensue. So that would total a $45,000 hit for the recoupment and the negative reimbursement. As I said this is an extreme example in terms of an audit taking a score from 100 to 0 and causing an 18% hit. However, even if the post audit total adjustment is only 6% that could be against those who chose group vs. individual MIPS reporting and have a much higher Part B billing. The average Medicare Part B payment for radiation oncologists is over $400,000 per year. A group of 5 would average over $2 million and an only 6% recalculation would produce a hit of $120,000. The numbers can grow large quickly.
CMS announced that the MIPS data validation and audit process began last month (June 2019) against performance years 2017 and 2018. Guidehouse was awarded a 5-year $14,000,000 contract to do the work. MIPS is more complicated than Meaningful Use and the stakes are much higher in terms of reimbursements. As we saw during the MIPS audits, documentation is the key to a successful outcome. Make sure you have your Book of Evidence complete and safely put away for the day that Guidehouse might come calling.