HHS Office of Inspector General flags MACRA vulnerabilities related to clinician awareness, program integrity

The Health & Human Services (HHS) Office of the Inspector General (OIG) in December 2017 released a report indicating that with regard to the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the Centers for Medicare and Medicaid Services (CMS) continues to face vulnerabilities related to clinician awareness of MACRA’s Quality Payment Program (QPP) and program integrity to avoid fraud and improper Medicare Part B payment adjustments.

In a similar report from 2016, HHS OIG highlighted vulnerabilities related to providing guidance and technical assistance to clinicians and to developing information technology (IT) systems to support data reporting, scoring and Part B payment adjustments. HHS OIG found that CMS has made “significant efforts” to address these vulnerabilities.


MACRA, which was enacted in April 2015, repealed the Sustainable Growth Rate (SGR) formula for updates to the Medicare Part B physician fee schedule (PFS) and set payment updates for all years in the future. At the same time, MACRA created two new Part B payment tracks for clinicians to establish the QPP:

  • The Merit-based Incentive Payment System (MIPS), which will provide positive or negative payment adjustments for clinicians whose practices are more closely tied to fee-for-service reimbursement; and
  • Advanced alternative payment model (AAPM) Qualifying Participants (QPs), for clinicians who have significant percentages of their practices in risk-bearing, coordinated care models in exchange for temporary financial bonuses and higher payment updates long-term.

Clinicians will be able to report data from the 2017 performance year to CMS from January 1, 2018, through March 31, 2018. Payment adjustments based on clinicians’ 2017 performance will apply to 2019 Part B payments.

The 2018 performance year began January 1, 2018, and will determine Part B payment adjustments and eligibility for AAPM QP bonuses for 2020.

HHS OIG December 2017 findings

In its December 2017 findings related to clinician awareness of the MACRA QPP, the HHS OIG raised concerns that if “clinicians do not receive sufficient information and assistance, they may struggle to succeed under the QPP or choose not to participate.” Importantly, MIPS-eligible clinicians who choose not to report data to CMS will face the full -4% payment adjustment for 2019 Part B claims.

The HHS OIG found that CMS has sponsored or produced a variety of technical assistance initiatives, but that the initiatives were often more general in nature, rather than approaching the level of an individual practice’s needs. CMS has said it will provide more targeted technical assistance for providers as the program takes effect.

With regard to its program integrity findings, the HHS OIG recognized that although the final rule for the 2017 performance period included program integrity provisions for MIPS and AAPMs, CMS still needs to develop and implement a “comprehensive program integrity plan,” including the designation of leadership responsibility for QPP program integrity.

HHS OIG cited as a particular concern potential vulnerabilities in the MIPS data submission system that could allow clinicians to “game” the MIPS scoring system by re-submitted data repeatedly to get a higher MIPS score than the one to which the user is entitled. This is a risk because the data submission system will provide a real-time score and indicate whether the clinician has received the maximum points available. The system then allows users to go back, complete the checklist again with different data, and see how that affects their score.

HHS OIG also raised concerns about the accuracy of MIPS data submitted by clinicians, particularly the self-attestation measures for Advancing Care Information (ACI) and Improvement Activities (IA). As an example of such a vulnerability being left unchecked, HHS OIG cited its previous finding that inaccurate attestation data under the Electronic Health Record (EHR) Meaningful Use (MU) program resulted in $729 million in improper payments from May 2011 through June 2014.

As CMS moves forward with development of a program integrity plan, it will be critically important for clinicians, health systems, and vendors to stay current with the related requirements as they plan their own reporting, data retention, and audit preparedness strategies.


Anne Phelps
Principal | Deloitte Risk and Financial Advisory
US Health Care Regulatory Leader
Deloitte & Touche LLP
Latest conversations from Anne Phelps on Twitter

Daniel Esquibel
Senior Manager | Deloitte Risk and Financial Advisory
Deloitte & Touche LLP

Ethan Joselow
Manager | Deloitte Risk and Financial Advisory
Deloitte & Touche LLP

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