Providers respond to Holder, Sebelius on 'troubling indications' of EHR fraud
Hospital organizations are responding to a stern letter sent Sept. 24 by U.S. Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius, which warns against using electronic health records to artificially inflate Medicare and Medicaid payments.
[See also: EMRs help docs document higher Medicare fees]
The letter – sent to the American Hospital Association, the Association of Academic Health Centers, the Association of American Medical Colleges, the Federation of American Hospitals and the National Association of Public Hospitals and Health Systems – expresses concerns over "troubling indications" that some hospitals are using EHR technology to "game the system, possibly to obtain payments to which they are not entitled."
As evidence, Holder and Sebelius point to "potential 'cloning' of medical records in order to inflate what providers get paid," and cite reports that hospitals may be using EHRs "to facilitate 'upcoding' of the intensity of care or severity of patients' condition as a means to profit with no commensurate improvement in the quality of care."
The letter reminds the hospital associations that, "False documentation of care is not just bad patient care; it's illegal."
The Centers for Medicare and Medicaid Services (CMS) is "specifically reviewing billing through audits to identify and prevent improperly billing," write Holder and Sebelius, and is "initiating more extensive medical reviews to ensure that providers are coding evaluation and management services accurately."
The Department of Justice, the FBI and other agencies "are monitoring these trends, and will take action where warranted," they add, noting that new tools provided by the Affordable Care Act authorize CMS to mine data to detect fraud.
Rich Umbdenstock, president and CEO of the American Hospital Association (AHA), responded in a letter sent to Sebelius and Holder that his organization agrees that cloning and upcoding "should not be tolerated." But he also pleaded for more specific guidance from CMS.
Umbdenstock wrote that EHRs "hold great promise for improving the efficiency and effectiveness of care" and also enhance hospitals' "ability to correctly document and code the care a patient has received."
He added, however, that, "It's critically important to recognize that more accurate documentation and coding does not necessarily equate with fraud."
CMS payment rules "are highly complex and the complexity is increasing," Umbdenstock wrote. "We have made numerous requests to [CMS] to develop national guidelines for the reporting of hospital emergency department (ED) and clinic visits. This is a request that the AHA has made to CMS 11 times (starting in 2001) since the outpatient prospective payment system (OPPS) was first implemented."