Much improper billing is well concealed

By Marla Durben Hirsch

Many are familiar with some of the more publicized EHR functions that can enable fraud, such as cloned notes, overdocumentation and "right coding," which can turn into improper upcoding.

"Some functions have legitimate uses so long as they're audited, but often they're not audited," according to Reed Gelzer (pictured right), 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.

However, there also are additional, unadvertised ways that EHRs can be used to compromise the integrity of the medical record and bill improperly, he warns. They include:

  • EHR functions or software that incentivize fraud by prompting the clinician or billing clerk to "correct deficiencies" and automatically add text in order to elevate billing codes. "If you don't, you get reports that show you what extra money you would have made had you just clicked that button," Gelzer tells FierceEMR. "In other words, if you cheat just a little bit, this is what you gain."
  • Templates for patient care that are already filled out based on expectations of what will be performed. "You proofread it but the machine is creating the record," Gelzer says. "It tempts the user to say [the documentation] is close enough."
  • The ability to alter the EHR but not show it's been altered, enabling the record to be changed to maximize billing. "There's no reason to alter surreptitiously," he says.
  • Functions build into EHRs that have no legitimate purpose, such as the ability to delete or corrupt auditing functions. "Legacy EHR companies will tell you that they built their systems when storage and data processing costs were high, so to economize don't audit anything. But [that's no longer the case, so there's no] need to manipulate, delete and corrupt audit functions," Gelzer points out.
  • Problems with source attribution. "Primary care physicians seeing 40 to 50 kids at a time with runny noses may create a template. It's tempting to copy boilerplate exams over and over," he says. "But if you look into the guts of the system, you see the record was created Monday and used on other days for other children, So the later records are not authentic."

"EHRs are proficient at creating records that look perfect," Gelzer warns. "Unless you ask pointed questions, it looks authentic when it's not."

Of course, most providers are not actively trying to commit fraud, points out Ann Sheehy (pictured left), an associate professor and division head of hospital medicine at the University of Wisconsin Department of Medicine in Madison. However, Gelzer says, clinicians--some of them still learning how to best use EHRs--are running into trouble with documentation issues, causing them at best to make mistakes. And sometimes the EHR functions create a "moral hazard.".

Others agree. "Some EHRs use as a selling point that the system will help you obtain higher reimbursement," 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.

The ultimate problem is that the unauthentic EHRs also pose medical risks.

"What does this mean for a patient? Medical records are often not challenged for their authenticity," Gelzer says.

Read More:
Much improper billing is well concealed