EHR billing fraud: More than a numbers game

There's a well-known adage in business that 10 percent of people will never steal, embezzle or commit fraud; 10 percent will always steal, embezzle or commit fraud when they can; and 80 percent will do it under certain circumstances when given the opportunity.

That might finally explain what's occurring with electronic health records and billing fraud.

A recent study published in Health Affairs found "no evidence" that hospital EHR users were engaged in improper billing.

But we also have seen evidence from the New York Times, the Center for Public Integrity and elsewhere that the functionalities in EHRs--such as cloning--enable clinicians to overdocument and bill improperly.

On top of that, there's software that "corrects deficiencies" in EHRs by suggesting higher level codes that can be obtained by merely clicking on a button and showing the provider what reimbursement it has lost out on if it doesn't do so. "If you cheat just a little bit, this is what you gain," Reed Gelzer, a co-facilitator with the HL7 EHR Records Management and Evidentiary Support Profile Standard Workgroup and head of the consulting firm Trustworthy EHR in Newbury, New Hampshire, recently told FierceEMR.

There also are EHRs that allow providers to alter patient records after the fact, but not show that they've been altered, as well as templates that complete themselves so the clinician doesn't have to, according to Gelzer.

It's not that EHRs themselves increase billing fraud. They increase the temptation for the 80 percent.  

Of course, most providers are not actively looking to commit fraud, and there's a big difference between "right coding" and fraud.

Take a look at the software that corrects deficiencies to obtain higher revenue. For a clinician or coder who is incentivized by increased revenue or receives a salary bonus by billing more, that's an opportunity that individual otherwise would not have had. But at what point does the software jump from right coding to improper coding?

"These functions tempt or provide incentives for moral hazard," Gelzer said.

Or what about an EHR program that allows the record to be altered after the fact? Why should any patient record have that capability? Doesn't that create an atmosphere where someone can commit fraud more easily?

It's a bit like taking office supplies from one's employer or finding a wallet in the parking lot. If one knows he's being watched, he's more likely to leave the supplies alone or turn in the wallet. But if there's an opportunity to get away with it, a greater percentage of people will pad their pockets a bit more.

Perhaps the hospitals where there was "no evidence" of fraud simply didn't have the opportunity. The Health Affairs study only looked at data. It apparently didn't look at EHRs themselves, or whether the hospitals policed their use via auditing and other means. Plus, the data used was from 2008 through 2010, before the Meaningful Use program pushed providers into adopting EHRs and before "correct deficiency" software and other "opportunities" to commit fraud were widely available.  

It's hard to ferret out Medicare fraud. Just look how long it took Medicare to stem the tide of power wheelchair fraud, as reported this past week in the Washington Post. And arguably, that kind of fraud is easier to spot. EHR records, on the other hand, can, on their face, look perfectly legitimate. It's only when one delves into the details that the problems are discovered.

But here's the kicker. Manipulating patient records to increase reimbursement, even if only a little bit, can compromise the patient record. It's no longer reliable and authentic, Gelzer warned. That can have a major, nationwide adverse impact on patient care.

Cheating, even a little bit, is still cheating. And what's worse is that we, the American tax payers, are the ones getting cheated the most. Every improper code and claim paid for is money that could have been used elsewhere, for people who deserved it. - Marla (@MarlaHirsch and @FierceHealthIT)