Post Payment Audit and Appeals

The Health Information Technology for Economic and Clinical Health Act of 2009 requires states to ensure the accuracy of EHR Incentive/PI Program payments disbursed to eligible professionals and eligible hospitals. Program integrity operations include pre-payment verification of various eligibility and meaningful use requirements before issuance of a payment. The pre-payment verification is not a comprehensive review, nor a formal audit. Pre-payment verification does not preclude an EP being selected for a formal post-payment audit, which requires additional and more detailed documentation to be produced. HHSC conducts post-payment audits of payments to eligible professionals and eligible hospitals participating in the incentive program, to comply with the oversight requirements stipulated by the Centers for Medicare & Medicaid Services. HHSC contracts with an independent audit firm to conduct audits of incentive payments on behalf of the state.

Representatives of the audit firm contact providers who have been selected for audit. If you receive a notice of audit, respond within 10 days with all requested information. The information you provide will be used for the sole purpose of the Texas Medicaid EHR Incentive/PI Program audits.

If you transmit information to the audit firm containing Health Insurance Portability and Accountability Act Protected Health Information of Medicaid clients, the transmission must be compliant with existing provider contract and regulatory requirements that the data be adequately safeguarded. For example, electronic PHI should be encrypted when emailed or mailed using secure portable media, such as an encrypted compact disk or flash drive. Providers can also upload data securely and directly through the EHR Incentive/PI Program Portal which uses HIPAA-compliant encryption technology. PHI mailed in hard copy (paper form) should be mailed securely and marked confidential.

Note that federal regulations require eligible professionals and eligible hospitals to save auditable documentation to fully support their attestations for a minimum of six years from the date of their attestation. Failure to keep proper and complete records could result in an adverse audit finding and recoupment of a previously issued incentive payment.

More Information

States are required under 42 Code of Federal Regulations §495.316 to conduct audits of payments to eligible professionals and eligible hospitals, referred to as providers, participating in the Texas Medicaid EHR Incentive/PI Program.

HHSC follows policies and procedures related to audit notifications and review of audit findings in accordance with Texas Administrative Code Title 1, Part 15, Chapter 356, Subchapter B, §356.202, “Audit Review and Recoupment,” and TAC Title 1, Part 15, Chapter 354, Subchapter B, §354.1450, “Audits of Medicaid Providers.”

For questions related to appeals, email us at EHR_audit_appeals@hhsc.state.tx.us.