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Meaningful Use: How to Survive an Audit Request

Monday, April 13, 2015 Cathy Borst, Vice President and CIO,

National Surgical Healthcare Patty Guinn, RN, BS, Director and Practice Leader for Clinical Informatics, Cornerstone Advisors Group, LLC

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

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Conflict of Interest Cathy Borst ―Has no real or apparent conflicts of interest to report. Patty Guinn, RN, BS ―Has no real or apparent conflicts of interest to report.

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Learning Objectives • Recognize why it is important to establish your Book of

Evidence at the time of attestation

• Explain the six step process designed to effectively manage the evidentiary documentation from inception through audit submission

• Explain how with appropriate planning and organization, responding to an audit notification letter within the allotted timeframe is very doable

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Overview

Organizations have spent millions pursuing Meaningful Use –

some with success, more than a few still struggling. This

presentation will examine how to:

• Prepare the evidentiary documentation needed for proof of

meaningful use

• Streamline the audit preparation process

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About National Surgical Healthcare • NSH is a forward-thinking and decisive leader in managing surgical

facilities. We are trusted operators with experience building successful partnerships through value-creating growth.

– Founded in 1998 – NSH has grown to a portfolio of 20 surgical facilities across 12 states. – NSH has a successful track record in partnering with facilities that

have developed a strong market presence and are led by high-quality surgeons.

– Many NSH facilities have been awarded “Center of Excellence” designations due to exceptional clinical outcomes and high patient satisfaction scores. Notably, several facilities are ranked first or second in patient satisfaction by HCAHPS in the states in which they operate.

– More information available at National Surgical Healthcare

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The Issue at Hand • Meeting Meaningful Use (MU) requirements can be

formidable when considering their: – Implementation

– User adoption and accountability

– Associated financial risk

• When an audit notification letter is received, what was already formidable now also becomes daunting and stressful.

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Audits on the Rise • Now that participating eligible hospitals are past the first few

years of demonstrating MU, audits are on the rise with more and more letters going out each year.

• According to Robert Anthony (Deputy Director of the HIT Initiatives Group, Office of E-Health Standards and Services at CMS) the CMS projects a 5% audit rate for hospital facilities that have attested.

• Figliozzi and Co. report a 4.7% failure rate for first time audits.

• Most experts say it’s a matter of when, not if, audit notification will be received.

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Our Experience • At National Surgical Healthcare (NSH), 7 out of 12

facilities or 58% were audited for MU Stage 1 Year 1.

– The audit letters all came at the same time

– There was only a four week turnaround time allotted for each audit response

– All 7 responses were due on the same date

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Approach • This presentation will examine:

– The critical components of the evidentiary documentation (Book of Evidence) lifecycle including preparation, review, and packaging so that the response may be as streamlined and organized as possible

– A six-step process for managing the Book of Evidence through audit submission

– A case study based on NSH’s actual Year 1 Stage 1 audit response experience

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Additional Topics to Be Covered • We will discuss the key success factors based on

lessons learned for the Book of Evidence • Because MU is ongoing – and the lessons learned

are applicable to the ongoing Stage 1 attestations as well as future stages and attestation cycles – suggestions for how to integrate the lessons learned into your next attestation cycle will be explored.

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The Six Step Process: From Inception through Audit • Pre Attestation Period – Steps 1 and 2

1. Understand the MU evidentiary requirements 2. Define/validate the required reports

• Post Attestation Period – Steps 3, 4, and 5 3. Run and validate the reports 4. Compile the BoE using Audit Prep Tool 5. Perform Mock Audit

(Note: NSH did not conduct a mock audit) • IF Audited: Receive the notification letter – Step 6

6. Prepare and submit the response

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Step 1 – Understand the MU Evidentiary Requirements • Conduct regular ARRA/MU Meetings with EMR

Vendor and any other vendor assisting with MU tracking or reporting

• Utilize publically available websites and forums: – CMS Website for documentation by objective – Vendor and User Community List Serves – Healthcare specific email/industry alerts and webinars

• Discuss requirements and interpretations with consultants and peer facilities

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Step 2 – Define/Validate the Required Reports Step 3 – Run and Validate Reports

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• Requires that you work with your EMR and/or MU reporting vendor regarding which reports should be utilized by objective based on certification.

• Must run reports to ensure appropriate fields and triggers are properly set to populate the reports for attestation.

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Step 4 – Compile the BoE • Both in preparation for and during attestation, NSH

stored documents on a restricted file share by facility and by objective. This included:

– Screen prints (i.e. CDS Rules) • At the beginning and end of attestation period

– Reports • Patient List during the reporting period • Attestation Reports covering the Reporting Period

– EMR Vendor Certification Letter – Evidence of PHI Testing and/or Go-lives

• Test and/or Live Interface Message • Correspondence with State (Letters, Emails)

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Why Develop the Book of Evidence at the Time of Attestation? • Most reports can be corrected if necessary

– Unless archived off, the database used for re-running reports will be the production database which is dynamic.

– Some patient data will change due to changes in ADT (merges, combines, data posted to incorrect accounts) and reports will not generate the same denominators and numerators later in the year.

• It is an insurance policy – People are focused on the data at the time of attestation. – Assumptions are current and may be used to compile and document the

Book of Evidence before they are forgotten. – Turnover may occur. The people who were involved in attestation

may not be available at the time of audit and those left to pick up the pieces will most likely struggle to understand why something was or was not done at the time of attestation.

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Is There an Alternative? • If it isn’t possible to create the Book of Evidence at

the time of attestation, the best alternative is archiving the production database so it is available to support audits and Book of Evidence preparation at some point in the future.

– The only way to preserve the data and have accurate report re-runs is to take a snapshot of the database at the time the reports are first generated.

– If this is not done, the reports will produce different results because the database will change over time.

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• Provides the opportunity to validate the evidence collected and address additional documentation needs before the audit.

• Creates the use of audit tools such as: – Response Tracking – Issue Log – Communication Plan

• Provides the organization with the opportunity to be proactive by verifying evidence and fine tuning the process before an audit request is received (rather than having to be reactive after the fact).

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Step 5 – Run Mock Audit (Optional, but recommended)

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• NSH Experience: – Reviewed existing evidence and tracked it in a log

(working file) including a strength rating. For materials that were not rated as Strong, ensured we had supplemental/supporting material if asked. (See sample Tracking Log on slide 20)

– Created a separate folder structure for Figliozzi (subset) based on review of materials and finalized evidence for submission (redacted)

– Standardized and formalized response with an Overview document summarizing the requests, the zip file and files names included addressing the request. (See sample Overview after Tracking Log example)

Step 6 – Prepare and Submit Response (If Audited)

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• NSH Experience: – Had one resource complete the upload for consistency

and retained a screen print of the upload as evidence

– Asked sites to follow-up with their Figliozzi contact to confirm receipt.

– Responded to follow-up questions following this formal process

– Retained Audit Determination Letters evidencing each set met the criteria (passed)

Step 6 – Prepare and Submit Response (If Audited) cont.

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Step 6 – Prepare and Submit Response – Example Tracking Log

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Step 6 – Prepare and Submit Response – Example Overview Submittal

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Challenges and Barriers Faced – Summary • Although there are many challenges when faced with a

MU audit, there are three key challenges that rise to the top when considering an audit response:

1. Time constraints 2. Database integrity 3. Communication

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Challenges and Barriers Faced – 1. Time Constraints • The most significant challenge is clearly the timing of the audit

and the short turnaround time allotted by Figliozzi and Company (Figliozzi).

• Figliozzi did allow for additional time for the sites that “missed” the initial email notification

• For NSH, the five-facility response required a review and aggregation of approximately 60 documents per facility, for a total of about 300 documents, within the three-week window.

• The two additional facility audits took less time, as NSH prepared most of the materials for all sites during the initial request time frame knowing any of them could be audited.

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Challenges and Barriers Faced – 2. Database Integrity • Database integrity is critical when preparing for an audit

response if reports need to be either re-run or edited because of formatting issues.

• When reports are run from the production database, it is highly unlikely that a report which has to be re-run will match the original generated at the end of the attestation phase.

• A report submitted to Figliozzi that does not match the attestation numbers will trigger a huge red flag.

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Challenges and Barriers – 3. Communication • Effective and efficient communication is paramount when

coordinating the response – especially when there are multiple facilities involved and accountability for meaningful use is decentralized.

• Even when accountability is centralized, the audit notification letters are sent to the individual facilities and, because the notification letters are electronic, the notification letter may land in spam folders or may be considered spam by the end user and deleted. Note: Two of the 7 NSH hospitals audited had this experience.

• Beyond the coordination of documentation, the audit response is high on executive leadership radar which means that proactive communication is crucial so the response team may focus on preparing the response with as little interruption as possible.

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Critical Success Factors and Lessons Learned • Critical Success Factors

– Effort put in to preparing the Book of Evidence in conjunction with attestation

– Use of a Tracking Log and clear process to review and organize the materials

– Organization and attention to detail

– Communication

• Lessons Learned – Validation of denominators

– Formatting of reports

– Treatment of PHI

– Supplemental Documentation (i.e. EMR and Formulary Vendor Invoices)

– Resource needs

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Conclusions and Outcomes Achieved • A successful audit response is heavily weighted on the Book

of Evidence prepared at the time of attestation.

• The outcome achieved by the combination of a well-defined Book of Evidence and a well-managed audit preparation process was a three-week turnaround on a MU Stage 1 Year 1 audit request for five hospitals.

• Further, approximately 300 documents were reviewed, organized, successfully packaged and submitted during this same three-week timeframe.

• The responses submitted by NSH were not only well organized and complete, they were submitted five days before the due date for all five facilities.

• All 7 facilities successfully passed their Stage 1 Year 1 audits on first submission. No appeals were necessary.

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http://www.himss.org/ValueSuite

S: The outcome demonstrates that a well-thought out and executed MU documentation management program will make the audit response manageable and relatively low-stress.

T: The six-step process is directly correlated to achievement of meaningful use.

E: The six-step process requires minimal printing as the majority of work is computer based.

P: The MU documentation management process is a defined six-step process that can be followed by any organization and will result in a well prepared audit response.

S: There are never any guarantees; however, a timely audit response that is highly organized and well documented helps mitigate the risk of financial penalties as an outcome of the audit. The six-step process also allows the organization to plan and manage the work rather than being put into a reactive mode with unplanned work hours and risk of not meeting deadlines.

An Introduction to Benefits Realization for a Structured Approach to a Meaningful Use Audit

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Questions? Contact Information Cathy Borst VP & CIO National Surgical Healthcare 250 South Wacker Dr. Suite 500 Chicago, IL 60606 T: 312-627-8419 cborst@nshinc.com Patty Guinn, RN, BS Director and Practice Leader, Clinical Informatics Cornerstone Advisors Group, LLC PO Box 569 Georgetown, CT 06829 T: (678) 570-0577 pguinn@cornerstone-advisors.com

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