EHRs increasingly the target of fraud fighters

Buried in the U.S. Department of Health & Human Services' Office of Inspector General (OIG) otherwise dry report last week on electronic health record use by physicians is what I suspect is the real reason the OIG conducted its inquiry: whether physicians were appropriately using the auto-generated data features in their systems.

This is significant. Not as to whether physicians are using auto-generated data--I'm sure there are many--but that the OIG has turned its guns on it, just like the OIG said it would in its 2012 work plan, released last October.

Think about it. There are plenty of consultants, associations and other government entities who have regularly reported on EHR use by physicians. Since when does the OIG care how many physicians adopted EHRs and when? The OIG's raison d'être is program integrity. It's looking at whether those physicians using EHRs are committing billing fraud against the Medicare and Medicaid programs.

And the fact that it was the Office of the National Coordinator for Health IT that asked OIG to conduct this investigation, as noted in the report, speaks volumes. All of HHS will be keeping a close eye on whether EHRs are being used, intentionally or not, to upcode or commit other fraud. The OIG report notes that a related report on "documentation vulnerabilities" involving EHRs will be published separately and that "subsequent evaluations" are forthcoming.  

It just so happens that none of the physicians the OIG randomly targeted for review was found using the automatic coding feature in their EHR systems. If they had been, it's possible that they would have become the targets of further investigation.

But focus on EHRs is not limited to government payers. Private payers, also keen to ferret out improper billing, are stepping up their investigations of providers whose EHRs appear to be generating improper bills.

For instance, one physician recently found himself on the hot seat with a large payer for using auto-generated features in his EHR. He was using the features to make documentation and billing easier, since many of his patients had the same chronic conditions and received similar periodic treatments. The payer accused him of cloning notes and upcoding, and denied payment of his claims to the tune of about $50,000, according to Ashland, N.H.-based attorney Robin Fisk, who is familiar with the situation.

The physician eventually prevailed and was paid most of his claims, but had to hire both an attorney and an independent coder and meet with the payer to prove that his documentation was legitimate.

So here's a function of an EHR that's touted as a benefit to simplify workflow, capture revenue that's sometimes left on the table,  and make documentation searchable, and it's backfiring, creating unnecessary work. "If you have to go back and compose something different each time and tweak every note to make it unique, that makes the EHR harder to use," Fisk tells FierceEMR.

It also can increase one's legal risk.

Providers, please consider this fair warning: If you're going to use your auto-generated data features, please make sure you're doing so in accordance with the law. The payers have this issue in their crosshairs. - Marla