Annals of Health Law
READY OR NOT
would involve a procedure to accommodate newly announced quality
measures, which CMS has cautioned could be issued in as few as sixty days
prior to the commencement of the applicable performance period under the
C. Compliance Role in Tracking Overpayments and Preparing for Quality
As previously discussed, CMS is expected to audit hospital data arising
out of VBP claim submissions. Providers that choose to report quality data
through the attestation tool276 are advised to retain medical records and all
supporting documentation for at least six years following attestation.277
Moreover, any assumptions made by clinical or administrative staff when
evaluating and entering quality data into their EHR or attestation tool,
should be well documented since the descriptive language for some quality
measures leaves room for varying interpretations.278 Compliance
professionals should make certain that the attestation process is carefully
monitored and that the attesting professionals are well informed as to the
significant legal implications associated therewith.
2011), available at http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/
275. See Healthcare Reform Meets Hospital Operations: Healthcare Reform
Roundtable, MORGAN LEWIS (June 29, 2010), available at
276. See Section IVC.
277. See supra notes 178-80 (CMS has instructed providers who submit CQMs in order
to satisfy EHR incentive program requirements to retain all primary and supporting
documentation in paper and electronic formats, for at least six years, in preparation for
278. See EVERYTHING HITECH, supra note 179 (although not required by CMS,
recommending providers create copies of patient level detail to substantiate the accuracy and
completeness of the data as to each measure).
279. See supra Section IVD.
280. See id.