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Avoiding and Appealing CMS Audits

June 17, 2013

how to avoid cms auditsAvoiding and appealing CMS audits

Last April, Figliozzi & Company, Certified Public Accountants, was awarded a contract by CMS to perform audits of those Medicare providers, as well as dual-eligible Medicaid and Medicare providers, who have attested to meaningful use and have received incentive payments under the Medicare or Medicaid EHR (electronic health records) Incentive Program.

What is involved with a CMS audit?

All Eligible Professional (EPs) who are participants in meaningful use of electronic health records (EHR) are potential candidates for being audited. For the period beginning with 2011, the CMS has already started auditing selected practices, as well as conducting pre-payment audits for 2012. If the audit determines that the Meaningful Use requirement for even one of the measures has not been met, the entire payment must be repaid. There are as now no provisions for partial payments.

If targeted for an audit, it’s important to know that, at the time of this writing, your practice will have only two weeks to respond to and assemble the necessary documents. By keeping careful records submitted for attestation by the EHR system, the EP can prepare for, and possibly appeal a negative finding that would require your practice to refund any incentive payments for meaningful use.

What information will you need to produce if audited?

Information currently being requested by Figliozzi & Company includes:

  • A copy of technology system’s certification
  • Supporting documents of the reporting methods used for reporting emergency admissions
  • Supporting documents for attestation module responses pertaining to the core set of measures and objectives.
  • Documents that support attestation module responses relating to the menu set of measures and objectives.

The CMS advises practices which may be targeted for an audit to keep all documentation that supports attestation. You should keep all post-attestation documents for a minimum of six years following the initial use.

What course of action should you take if you believe the audit decision was an error?

The CMS’s Office of Clinical Standards and Quality (OCSQ) offers EPs who disagree with the decision a two-tier way to appeal a finding. This consists of an informal review as well as a reconsideration request. As a rule, EPs can file an:

  • Incentive Payment Appeal
  • Eligibility Appeal
  • Meaningful Use Appeal
  • Eligible hospitals and CAHs filing for Incentive Payment Appeals are referred to a Provider Reimbursement Review Board for decision.

It is critical to file an appeal within the designated deadline – refer to the CMS appeal pages for specific updates on these. Appeals may be filed via email at: or by calling a toll-free hotline: 855-796-1515 from 9 a.m. to 5 p.m. Monday through Friday.

Download: RAC Audit Checklist – Simple Action Plan for RAC Audit Compliance

Extensions may be granted in limited extenuating circumstances; refer to the CMS Appeals PDF for more information.

Is it possible to simply avoid an audit?

While there is no guarantee that your practice will never be audited, there are ways to reduce the chances of this from happening. One of the best ways is to be sure your staff is fully trained and experienced in using the latest medical electronic health record (HER) technology as well as the codes and billing/ attestation procedures currently in place. M-Scribe Technologies , a leading medical billing and documentation company, offers experienced assistance to medical practices and clinics around the country with their documentation and billing needs.


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