All eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) attesting to receive an incentive payment for either the Medicare or Medicaid Electronic Health Record (EHR) Incentive Program may be subject to an audit.

Pre- and Post-Payment Audits

CMS and its contractor, Figliozzi and Company, perform audits on Medicare and dually-eligible (Medicare and Medicaid) providers who are participating in the EHR Incentive Programs. States perform audits on Medicaid providers participating in the Medicaid EHR Incentive Program.

In addition to the post-payment audits that have been conducted since 2012, CMS began pre-payment audits this year, starting with attestations submitted during and after January 2013.

New Resources to Prepare for Audits

For those providers selected for pre-payment or post-payment audits, CMS and its contractor will request supporting documentation to validate submitted attestation data. To help providers prepare for a potential audit, CMS created the new Supporting Documentation for Audits Fact Sheet. The fact sheet and a sample audit request letter for both EPs and eligible hospitals are also available on the Educational Resources page of the EHR Incentive Programs website.

Additional Information About the EHR Incentive Programs?

Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

Click here for additional resources from CMS regarding audit information and guidance.

Questions or request for more information? Please contact the CMS San Francisco Regional Office at (415) 744-3658 or rosfofm@cms.hhs.gov.

The U.S. Department of Justice filed a brief last Friday before the Ninth Circuit Court of Appeals arguing states can cut Medicaid (Medi-Cal in California) providers’ reimbursement as long as it does not harm access to care.

Earlier this year, SFMS/CMA have requested an en banc review from the Ninth Circuit as part of an effort to stop the State of California from implementing a 10% cut to Medi-Cal provider reimbursement rates.

In December 2012, a three judge panel of the Ninth Circuit ruled that the state could move forward with the rate cuts, passed by the Legislature in the spring of 2011, despite an earlier district court ruling that found that the cuts would irreparably harm the millions of patients who rely on Medi-Cal for health care. CMA and the other plaintiffs in the case are requesting a rehearing from the full Ninth Circuit Court of Appeals.

The justice department's brief urged the court to uphold the cuts and insisted that the Centers for Medicare and Medicaid Services (CMS) is not required to disapprove the plan amendments because they were motivated by “budgetary reasons.”

"It is entirely appropriate for a state to review its Medicaid plan to determine whether it can continue to satisfy its statutory obligations at lower payment rates," the justice department wrote in the brief.

CMA and the other plaintiffs in the case—California Dental Association, California Pharmacists Association , National Association of Chain Drug Stores, California Association of Medical Product Suppliers, AIDS Healthcare Foundation and American Medical Response—argue that reducing payments in the Medi-Cal system will force providers out of the program at a time when millions of new patients will be diverted into the Medi-Cal system.

If the state moves forward with these cuts, access to care will be devastated, not only for the existing Medi-Cal patients, but also the 900,000 kids moving from the Healthy Families program into Medi-Cal in 2013 and the millions of patients that will be newly eligible for Medi-Cal under the Affordable Care Act in 2014.

Governor Jerry Brown promoted his fiscal year 2013-2014 budget proposal and discussed several state health care initiatives in In his State of the State address yesterday. 

Budget Comments

Earlier this month, Brown released his budget plan. He said that if implemented, the proposal would leave the state with a budget surplus of $851 million. The plan projects $98.5 billion in revenue and transfers, and it estimates $97.7 billion in spending.

Brown's plan includes an expansion of Medi-Cal to individuals with incomes up to 138% of the federal poverty level. The expansion—included in the Affordable Care Act—is expected to add up to 1.5 million newly eligible adults to the program.

The budget plan also includes a 4.9% funding increase for In-Home Supportive Services—with an assumption that the state will implement a 20% reduction in IHSS service hours in November—and a $142 million funding increase for Cal-WORKs, the state's welfare-to-work program

In addition, the budget proposal allocates $1.6 billion for a court-appointed federal overseer to manage continued improvements in the state's prison health care system.

Health Care Comments

Discussing the Medi-Cal expansion, Brown called the initiative "incredibly complex" and said it will "test our ingenuity" and "will not be achieved overnight." He said, "Given the costs involved, great prudence should guide every step of the way."

Brown also said that the state must develop "the right relationship with the counties" to successfully implement the expansion.

Brown also called for a special session of the Legislature beginning next week that will focus on implementing ACA provisions.

Source: California Healthline, January 25, 2013.

Patient advocates across the nation are closely watching California’s transition of beneficiaries eligible for both Medicare and Medi-Cal from traditional fee-for-service plans to managed care plans.

The California initiative is in its second year. State officials seek to transfer so-called dual eligibles to managed care plans to improve their health care services and reduce costs.

The state has estimated that the initiative will save $663 million next year and that it will yield additional savings in subsequent years. Federal officials have begun implementing a similar national effort under a provision in the Affordable Care Act.

Howard Kahn—CEO of L.A. Care, the largest public health plan in the U.S. with one million members in Los Angeles County—said the California initiative allows health plans to organize all of the care that dual eligibles receive and curb unnecessary treatments. However, some patient advocates who have followed the California initiative wonder if the federal demonstration project will put patients at too great a risk.

A report released by the California HealthCare Foundation in August 2012 determined several problems with the transition, such as:

• A short timeline that allotted the state only seven months between federal approval and when enrollment began;
• Privacy rules that prevent some health plans from receiving complete patient records;
• Transfer guidance that confuses certain patients about whether their preferred physicians participate in various managed care plans; and,
• An appeals process that patients seeking exemption from the program find onerous.

According to Kaiser Health News, California's initiative has caused some patients to leave trusted physicians and others to start receiving generic drugs that they say are ineffective.

In addition, health experts have expressed concern that insurers participating in the initiative have little experience overseeing the long-term home care needs of certain dual eligible patients.

Source: California Healthline, December 6, 2012. 

The California Department of Health Care Services (DHCS) will soon be notifying physicians that they must re-enroll in Medi-Cal as one of the provisions of the Affordable Care Act (ACA). The ACA requires every state Medicaid program (Medi-Cal in California) to revalidate provider enrollment information at least every five years beginning January 2, 2013.

DHCS is currently working to identify an initial list of all physicians and other providers who will be required to revalidate. Notices of revalidation will be mailed beginning the second week of January 2013. Notices will be sent to business location on file with DHCS. Each notice will include information on which application(s) must be completed. Anyone receiving a notice must complete and return the requested form(s) and required attachments within 35 working days of the date of the notice. Failure to do so may result in payment delays.

Physicians, who have revalidated, updated, or submitted new applications to the Medicare program within the last 12 months (January 1 through December 31, 2012) will not be required to revalidate at this time. However, your Medicare enrollment information must match the information on file with the Medi-Cal program. If the information does not match, you will receive notice from DHCS requiring you to revalidate.

SFMS/CMA will be hosting two live webinar training courses with representatives from DHCS to walk attendees through the Medi-Cal enrollment process for both individual providers and groups. Also to be discussed will be program requirements and how to avoid common mistakes that can lead to delays, denials and exclusion from the Medi-Cal program. These extended-length webinars are free to members, and will be held November 15, 2012, and January 16, 2013, from 12:15 to 1:45 pm.

Click here for more information or to register for the complimentary webinar(s).