Mike Miliard, Managing Editor
Mike Miliard is Managing Editor at Healthcare IT News. Mike covers topics such as health information exchange, privacy and security, analytics and ICD-10. Follow Mike on Twitter @MikeMiliardHITN.
Providers respond to Holder, Sebelius on 'troubling indications' of EHR fraud
WASHINGTON | September 26, 2012
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."
Showing 4 Comments
bdcurn say: Upcoding?!?
September 28, 2012 | 09:34 AM GMT
This statement proves these two TRULY have never worked in health care nor with electronic medical record systems. In my previous work implementing EMRs in hospitals and physician practices, we often saw improvement in reimbursement because, for the first time, the physician could be confident that they had provided sufficient documentation to justify the procedure(s) they performed. In the past, for fear of being accused of fraud, they frequently chose a lesser code which meant less reimbursement.
As far as the "cloning" claim, many EMRs contain standard phrases and text that is auto-added to the record based on their selection of basic symptoms and exam observations (refer to SOAP charting).
Regarding "no commensurate improvement in the quality of care." That is also obvious: The physicians are still doing the same thing, but they are finally getting paid for the ACTUAL level of care they've been providing all along.
They should know enough about what they're claiming to have anticipated this OR have people around them that know what they're talking about. UNACCEPTABLE!!!!!!!
pjcasey75 say: Identifying fraud without defining it first?
September 26, 2012 | 13:58 PM GMT
Point 1 - let's acknowledge that the scenarios explicitly called out by HHS would qualify as fraud in anybody's book, even if we don't all have the same book.
Point 2 - However, if I read the AHA response correctly, it appears that CMS may be ready to accuse hospitals/providers of fraud despite having failed to respond to repeated requests since 2001 to provide national guidelines for legitimate coding of ER visits, that is, there is no regulatory standard to which hospitals/providers may look to in order to proactively comply.
If the concern about fraud expressed in HHS' letter is really based only on identified cases of cloned records, then that's fine by me. If however, the concern is based on the fact that EHR users are suddenly coding at higher rates than they did before, the Constitution assumes persons are innocent until proven guilty, with guilt to be measured relative to a statute, law or regulation in existence prior to the violation occurring or the charge being made. Historical averages (of CPT codes or of dollar claims values) should not be allowed to substitute for a set of clear guidance or regulations.
Ben Wolf say: fraud
Oh yes, there has always been the issue of intentionally documenting more to get a higher code, EHR's just make it easier to do so. Physicians see that "everyone else is doing it", and the 97 DG's are obviously just asking for computer templates to be used, so this is what you get. It is fraud and it is intentional, I mean a level 4 or 5 for everything? are these people really at risk of death? and how do you just make up a level 4 or 5 MDM and it not be fraudulent? They know what they are doing, they just figure the coding and reimbursement system is a big joke anyhow. In reality they are simply not trained to understand it, and should not be taking on responsibility for something they're not, dare I say, qualified to do. So the question is, what happens when their patients start to catch on to all this? How long do they think they can get away with charging for things they simply didn't do? Well I'll tell you, until they think there is a serious threat of being audited they'll rake in as much as they can and play dumb if they ever do get caught.