Providers: Fraud not the same thing as additional coding

There's a difference between more coding and healthcare fraud, according to provider groups, responding to the stern warning from the U.S. Department of Health & Human Services and the Attorney General earlier this week.

HHS Secretary Kathleen Sebelius and Attorney General Eric Holder on Monday sent a letter to five provider associations--the American Hospital Association (AHA), Federation of American Hospitals (FAH), National Association of Public Hospitals and Health Systems, Association of American Medical Colleges, and Association of Academic Health Centers (AAHC)--warning that the administration would not tolerate healthcare fraud fostered by electronic medical records.

Sebelius and Holder pointed to "troubling indications" that providers are gaming the system by falsely documenting and upcoding for higher reimbursements, the letter stated. 

The Centers for Medicare & Medicaid Services recently has boosted efforts to review improper billing and coding for evaluation and management (E/M) services, especially with new authority under the Affordable Care Act to halt payments for suspicious activity.

"We will continue to escalate our efforts to prevent fraud and pursue it aggressively when it has occurred," HHS and the Attorney General said.

AHA responded, saying although the hospital trade group supports HHS' hard-nose stance again EHR cloning and upcoding, "more documentation and coding does not necessarily equate with fraud," according to a Tuesday statement.

With more than half (55 percent) of hospitals qualifying for incentive payments under Meaningful Use, according to HHS, using EHRs could put hospitals and other providers in a sticky situation to more accurately code, yet they may run the risk of auditors interpreting increased coding and higher payments as fraud.

"One of the biggest selling points of EHRs is that this wonderful new electronic tool automatically captures additional data providers may have missed when manually coding, enabling providers to bill more accurately for their services. It's called 'right coding,'" FierceEMR columnist Marla Durben Hirsch wrote.

FAH similarly noted in its response, "EHRs increase the ability to capture meaningful data about each patient encounter. … We believe that any changes in coding reflect the fact that EHRs are enabling the development of more compete data sets regarding patient care and that these changes generally do not represent instances of inappropriate coding," according to a Tuesday statement.

FAH also suggested fraud was limited to a "few bad actors."

AHA and AAHC--the trade group that represents 100 academic health centers--cited a lack of clear, useful guidance about E/M coding from CMS--a request that AHA has asked for 11 times. In addition to a lack of national E/M guidelines, AHA also noted that rules for Medicare and Medicaid payments are only getting even more complex.

According to AHA's latest RACTrac survey, out of the 40 percent of denials that hospital appeal, more than three-quarters are overturned successfully.

For more information:
- check out the HHS announcement (.pdf)
- here's the AHA letter (.pdf)
- see the FAH statement (.pdf)
- read the AAHC letter

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