The federal government has spent the last 8 years trying to move doctors and hospitals away from paper records and toward electronic health record systems. Since 2009, with the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, there have been financial incentives and penalties attached to this push.
But now the government is also warning providers not to abuse the technology by engaging in fraud through either improper upcoding or the cloning of medical records. In a letter to five major hospital associations on Sept. 24, Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder wrote that some providers are using the technology to game the system.
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"False documentation of care is not just bad patient care; it’s illegal."
"False documentation of care is not just bad patient care; it’s illegal," they wrote.
This is a tricky area for doctors. The EHR industry has long promoted these systems as being able to produce increased revenue through better documentation and therefore higher coding. The idea isn’t that doctors would get paid for something they didn’t do, but rather that the system would help them to claim payment for the work they’ve always done, but never documented for appropriately.
Dr. William E. Golden, professor of medicine and public health at the University of Arkansas, Little Rock, said EHRs make documentation much easier – therefore doctors tend to document more. But more isn’t always better or more accurate in every case, he said.
The risk is that physicians are checking e-boxes for things they didn’t really do, or could be checking off things without even realizing it.
"Then you get into the question of validity," Dr. Golden said. "I think people are finding increasingly that the validity of what’s in the chart is not consistent."
This problem underscores the weakness of the current evaluation and management coding system, Dr. Golden said, adding that the situation could help to accelerate the move toward bundled payments and paying based on episodes of care.
In the Sept. 24 letter, Ms. Sebelius and Mr. Holder advised hospital executives that patient information must be individually verified. It cannot be cut and pasted from another record of the patient because of the risk of medical errors and overpayments. The Centers for Medicare and Medicaid Services is conducting audits to identify improper billing, they wrote. Agency officials are beginning more extensive medical reviews in whether physicians are coding evaluation and management services accurately, which could lead to payment reductions.
Ms. Sebelius and Mr. Holder are not the first ones to highlight of the misuse of EHRs in medical billing. The Center for Public Integrity, a nonpartisan, nonprofit investigative news organization, recently concluded a 21-month investigation into the higher Medicare billing that has emerged over the last decade, including upcoding through the use of EHRs. Most of the high coding, they found, was in hospital emergency departments.
But hospitals put the fault back on the government. Responding to the cabinet-members’ letter, the American Hospital Association noted that the Medicare and Medicaid payment rules are increasingly complex and that hospital EDs were using evaluation and management codes that developed with office-based physicians in mind. The AHA has asked the CMS 11 times since 2001 to develop national guidelines for the reporting of hospital ED and clinic visits. While CMS officials have stated in rulemaking that they would consider instituting guidelines, nothing has happened yet.
– Mary Ellen Schneider