Early Review of States' Planned Medicaid Electronic Health Record Incentive Program Oversight

We found that all 13 State Medicaid agencies in our study plan to verify at least half of the eligibility requirements for health care practitioners and hospitals prior to making Medicaid electronic health record (EHR) incentive payments, and that all also plan to audit eligibility requirements after payment. We also found that data availability limits both the number of eligibility requirements that State Medicaid agencies plan to verify prior to payment and the completeness of those verifications.

The Health Information Technology for Economic and Clinical Health Act, enacted as part of the American Recovery and Reinvestment Act, established Medicaid EHR incentive programs to promote adoption of EHRs. State Medicaid agencies administer their own Medicaid EHR incentive programs and are responsible for overseeing their integrity. Specifically, State Medicaid agencies must have an oversight plan that includes checking that health care practitioners and hospitals meet program eligibility requirements. State Medicaid agencies' oversight plans may include verifying self reported information for eligibility requirements prior to payment or auditing self reported information after payment.

Depending on the eligibility requirement, State Medicaid agencies may have none, some, or all of the data they need to conduct complete verifications prior to payment. For example, State Medicaid agencies reported that not all of the data needed to completely verify eligibility requirements involving health care practitioners' patient volume are available. Few States reported plans to collect all the necessary data because the effort would be resource intensive and logistically impractical for most States. State Medicaid agencies cannot conduct complete verifications for eligibility requirements without the necessary data.

The data limitations identified in this report affect States' ability to proactively ensure the integrity of their EHR incentive payments. Therefore, States should take these limitations into account when planning their program oversight. For example, States could strengthen oversight of their EHR incentive programs by focusing postpayment audits on eligibility requirements that cannot be completely verified prior to payment. Additionally, States that have not yet started their EHR incentive programs should note the potential inaccuracies in using Medicaid Management Information System claims data to verify Medicaid patient volume that we highlight in this report, and plan accordingly when designing prepayment verifications.