By Marla Durben Hirsch
Since the government and private payers are increasing their auditing and enforcement of improper billing related to EHRs, EHR users should consider taking several steps to avoid or reduce their risk of committing billing and documentation errors and to better defend them should they occur. Here are five:
- Have policies and procedures on EHR functionalities, such as when it's appropriate to copy and paste and how often electronic records will be audited, Ann Sheehy, an associate professor and division head of hospital medicine at the University of Wisconsin Department of Medicine in Madison, says. "These functions create efficiencies and are not disallowed but they need to be used responsibly."
- Make sure that the EHR system doesn't by its construction enable or encourage fraud. For example, the record needs to capture all authors to it, permit amendments in a way that shows it was amended and preserves the original record, and allows review to see how a record was created and whether shortcuts were used, says Reed Gelzer, co-facilitator of the HL7 EHR Records Management and Evidentiary Support Profile Standard Workgroup and head of Newbury, New Hampshire-based consulting firm Trustworthy EHR.
- Be careful when using EHR functionalities that could create documentation errors. For instance, don't copy entire sections of an EHR, be sparing in the use of auto complete functions and use free text to include individualized information in the note. "Put thought into the record," Sheehy says.
- Review the records you're creating to make sure that they're correct. "It's important to validate the accuracy of the information you're putting in," Sheehy says.
- Protect the integrity of the records from third parties. Make sure that the appropriate person is entering the information into the system. "Don't give your password out and let others populate the system," says Dan Bowerman, a chiropractor in Philadelphia formerly with a large payer's special investigations unit who now works regularly with OIG, the Federal Bureau of Investigation and other government entities to uncover healthcare billing fraud.