Healthcare // Electronic Health Records
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EHRs Under Fire For Inflating Medicare Bills

HHS, Center for Public Integrity say some healthcare providers are gaming the system to draw higher Medicare reimbursement. Doctors say electronic health records are simply enabling them to bill for things they had done for free in the past.

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The Obama administration has escalated its battle against healthcare providers that submit falsely documented Medicare claims using electronic health records (EHRs). In a letter sent Monday to major national medical organizations, Department of Health and Human Services (HHS) secretary Kathleen Sebelius and attorney general Eric Holder said, "There are troubling indications that some providers are using [EHR] technology to game the system, possibly to obtain payments to which they are not entitled." The Cabinet-level officials also committed to stepping up audits and law enforcement to fight the practice, which results in health care fraud, they said.

Sebelius and Holder said in the letter that "Used appropriately, [EHRs] have the potential to save money and save lives." They went on to say that "there are also reports that some hospitals may be using electronic health records to facilitate 'upcoding' of the intensity of care or severity of patients' condition as a means to profit with no commensurate improvements in the quality of care."

The Center for Public Integrity (CPI), an investigative news organization, last week posted an article documenting the use of electronic health records (EHRs) to justify higher evaluation and management (E&M) codes that it says are costing Medicare billions of dollars a year.

The third report in a five-part series about hospitals' and physicians' use of "upcoding" to increase revenue, the article by Fred Schulte charges that federal officials ignored warnings about the ability of EHRs to help physicians raise coding levels because they were intent on increasing adoption of the technology.

Underpinning the investigative reports is a cross-section of Medicare claims data spanning the period 1999-2008. Based on an analysis of that data, the CPI article says, "The investigation unmasked thousands of doctors consistently billing higher-paying treatment codes than their peers, despite little evidence in many cases that they provided more care."

The CPI reports make clear that the use of EHRs--which was far from widespread in 2008--was only one element in the upcoding trend that the investigation revealed. Nevertheless, EHRs have provided new opportunities for upcoding, Schulte said in his article, citing anecdotal evidence as well as federal reports and whistleblower suits. EHRs and associated billing software have been used to inflate Medicare bills, he asserted, both in physician offices and hospital emergency departments (EDs).

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The core of the allegations is that EHRs enable doctors to copy and paste findings from previous notes into current notes, providing documentation that can be used to justify higher codes. While the issue of "cloned" documentation has been kicked around inside the industry for years, it is not known how many physicians use illegal tactics such as this to boost their revenues. What many doctors claim is that their EHRs help them document the work they actually did, which often results in higher codes than they might have put in if they didn't have an EHR.

The CPI article points out that Medicare auditors have stepped up their scrutiny of EHR documentation and the use of billing systems that prompt ED staffers to upcode certain kinds of visits. And last April, the Office of the National Coordinator of Health IT (ONC) asked the HHS Office of the Inspector General (OIG) to study the issue.

The CPI analysis of Medicare data does not establish a clear connection between upcoding and the use of EHRs, Schulte told InformationWeek Healthcare. However, he pointed out, "We contacted some of the higher-end hospitals and asked them about it, and they all said that EHR software is what's driving up our costs. Their position is that they've been leaving money on the table. Now they have a new electronic system, and they're cooking with gas."

Similarly, he said, physicians had told him and his colleagues that the use of EHRs had raised their average coding levels. "Some said they had been undercoding in the past." Moreover, he noted, EHR vendors pitch physicians on the ability of their products to increase income through higher codes.

Robert Berenson, MD, a senior fellow at the Urban Institute and a former Medicare official, agreed with Schulte. In an interview, he said that every provider he has spoken to believes that EHR documentation is related to the trend of higher E&M codes. "Some of the higher coding is legitimate, because it facilitates doing more work and documenting it, but some of it is illegitimate, because it permits gaming through exporting data [from previous visit notes]," he said.

Berenson contended that the design of EHRs has been distorted because of their emphasis on documentation to support higher charges. The reason that EHR vendors focus on documentation is that the Medicare rules require providers to count certain components in their records to justify E&M codes. He suggests changing the way that codes are defined and the guidelines for documentation.

"Unless you deal with the documentation issue, you've compromised the potential of the EHR," he said. "And from a reimbursement viewpoint, it's counterproductive."

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User Rank: Apprentice
9/30/2012 | 4:47:44 AM
re: EHRs Under Fire For Inflating Medicare Bills
If providers have been under-coding due to fear of being audited and their coding increases once they go-live on an EHR, there is nothing really wrong with that. It comes wrong when they keep copying their same documentation over and over without the need for it. Who has ever implemented an EHR where a physician hasn't asked if you can just make every visit copy forward and they'll change as needed? This idea would certainly tell the computer system that the visit is of a higher complexity and should be billed higher. People just need to keep it honest and there really shouldn't be much of an issue.
Jay Simmons
Information Week
User Rank: Apprentice
9/26/2012 | 8:10:08 PM
re: EHRs Under Fire For Inflating Medicare Bills
"The core of the allegations is that EHRs enable doctors to copy and paste findings from previous notes into current notes, providing documentation that can be used to justify higher codes. "

Really ... ???

I don't doubt that there are "allegations" about copy and paste, but is this different in substance from using "coded comments" in computerized reports for radiology, pathology, clinical history, etc.? Is this different in substance from entering "WNL" for an organ system examination (e.g., Neurological Exam) on a History and Physical?

The legal argument to be proven is analogous to proving that WNL actually means "We Never Looked." Whether a doctor presses a key (say, "F7") and the EHR generates a lucid, readily understood description of some clinical observation/interpretation or if the doctor copies that same text from a previous clinical record of the same (or another patient with the same condition) should be immaterial.

Standardized text that is continuously reviewed in clinical usage is more likely to be correct, complete and consistently interpreted -- it doesn't mean that the clinical evaluation is missing. It can be an indicator of refined clinical processes ... although it does carry an associated risk of mental short-cutting and not fully thinking through what is going on. Standardized text is a good tool for improving communication, but it needs continuous monitoring of its usage.

User Rank: Apprentice
9/26/2012 | 7:52:57 PM
re: EHRs Under Fire For Inflating Medicare Bills
(1) Under-coding becomes "unmasked" when an EHR is implemented because there must be full documentation of the requisition-work-coding-billing process -- it is likely that just a review of processes is sufficient to discover that the old system of coding work has been missing a significant amount of billable activity. Back in the 1970's laboratory computer vendors were justifying their cost by saying that they'd increase collections for undocumented billable activity.

(2) The "fear factor" comes in to play with Medicare audits. If the audit finds that a certain high dollar procedure (for example, MRI) has not had the "clinical indication" for that procedure documented in (say) 10% of a sample of 20 cases, the imaging department may have to cough up 10% of Medicare receipts for that procedure for several preceding years -- that is certainly sufficient to get one's attention about proper documentation.

(3) An "enlightened" administration of a hospital, clinic or other facility has a vested interest in accurately reflecting all work activity that was actually done by clinical and technical staff in the codes submitted for reimbursement ... and should have an equally strong interest in NOT billing for things that were not done. Absent such "enlightenment", one can only speculate on the behavior pathologies that might result!
User Rank: Apprentice
9/25/2012 | 10:51:16 PM
re: EHRs Under Fire For Inflating Medicare Bills
"the administration and his puppets" Really? How old are you?

Look, the issue is not about practitioners and hospitals billing what is rightfully due to them. Rather, the issue is about the age old phenomenon of greed and gaming that all the bad apples seem eager to perpetuate. They just have another tool now to help them do it.
User Rank: Apprentice
9/25/2012 | 5:47:51 PM
re: EHRs Under Fire For Inflating Medicare Bills
Well, I hate to say it...but I told you so. Its was obvious this would happen. Providers were under-coding in fear of audits showing not enough documentation to code. Now with EMR's they are comfortable in knowing their note justifies the E/M code. Physicians are only getting what is due for many years of fear and under-coding. CMS in all their brilliance could have asked any one in the EMR industry what would happen and they would say, yes coding is going to increase. So now the administration and his puppets are going to use fear tactics to coral the provider again. So the practice changes to EMR as they are nearly forced to do, use it properly and now are being warned to "stop it". Not to mention CMS now and soon being able to scrutinize all EMR Meaningful User's with CQM's being submitted.
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