OIG: MACRA reporting may be too easy to abuse

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 - Fraud

CMS has mostly solved issues with deploying the IT infrastructure to manage data submission for the Quality Payment Program (QPP) set up by the Medicare Access and CHIP Reauthorization Act (MACRA), according to the HHS Office of Inspector General (OIG). Program integrity and technical assistance, however, still need work.

The OIG report particularly singled out the lack of a “comprehensive program integrity plan for the QPP,” saying while CMS has begun oversight planning by including provisions in the final MACRA rule for 2018, it has yet to appoint someone to lead the charge on preventing and addressing fraud and improper payments in the QPP.

Reporting for the Merit-based Incentive Payment System (MIPS) is particularly vulnerable to fraud, OIG said, because it relies on clinicians on submitting their own data—and allows them to resubmit data to change their score.

“Once the user completes the checklist, the system will provide a real-time score and indicate whether the clinician received the maximum points available. If users are not satisfied with their first score, the system will permit them to go back, complete the checklist again with different answers, and see how that affects their score,” the report said. “Although users may resubmit their data to obtain the highest score to which they are lawfully entitled, this same resubmission process could be abused if users submit inaccurate data solely for the purpose of obtaining the maximum possible points.”

CMS has said it will be able to review how and when clinicians change their submitted data, but OIG said this wasn’t designed to facilitate oversight and the agency’s lack of an integrity plan means there’s no assurance the reviews will be conducted.

Without a clear strategy to prevent and root out fraud and abuse, OIG said CMS is in danger of repeating past mistakes, like when the agency erroneously paid out $729 million in Medicare electronic health record (EHR) incentives to clinicians who didn’t comply with program requirements.

There have been improvements since the last OIG report on MACRA, issued in Dec. 2016. Since then, CMS has appeared to catch up on completing the IT systems needed to collect data from clinicians.

Whether clinicians will be ready to do so, however, remained a concern. While CMS has conducted outreach, awarded technical assistance contracts and made other efforts to ease the transition, the OIG report said clinicians are still uncertain about key elements of the program.

“If clinicians do not fully understand how to participate in the QPP, or if they lack the tools and support to make the practice changes necessary to respond to QPP incentives, the program may have limited success,” the report said.

CMS seemed to acknowledge this issue, saying it would steer outreach to “more specialized technical assistance” in the second year of reporting. The old issue of clinicians lacking awareness of the program—a widely-reported issue in 2016—does appear to have been solved.

“The tone and tenor of the types of questions the contractors are receiving will change from ‘What is this?’ to ‘How do I do it?’ So, (the amount) of hands-on, customized technical assistance (provided by contractors) is likely going to increase as clinicians move beyond their initial awareness of the program,” said one unnamed CMS official quoted in the report.