How private payers detect EHR-enabled fraud

By Marla Durben Hirsch

Private payers have become more savvy in ferreting out problematic claims based on EHRs, by both using automated software and more sophisticated claims review to catching anomalies unique to EHRs, says Dan Bowerman (pictured), 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..

"Since the error or fraud is camouflaged, they look for tip off points that something is wrong," Bowerman tells FierceEMR.

Some of the abnormalities payers look for during a claims review or audit of an EHR user that may trigger a more thorough analysis of a provider's billing practices include:

  • Boilerplate records that overlap, either page after page, over time, or from one patient to another, which indicates inappropriate use of copy and paste.  "The weight, height and blood pressure [of a patient] is not the same for every visit," Bowerman says.
  • Encounter information that lacks individualized information about the patient, which indicates that the documentation was computer generated or assisted
  • Gender confusion in a note
  • Long records for each encounter, which makes it more likely that records have been enhanced by computer
  • Records with a lot of blanks, which indicate use of an automatic template without much or any clinician input
  • Repeated typos and spacing errors that indicate copy and paste and nonsensical phrases that indicate cut and paste. "Things are just cobbled together," Bowerman notes.
  • Inconsistencies within a record, such as a complaint of headache with a detailed exam of the lower extremities, or complaint of headache but a review of systems stating no headache
  • Use of similar phrases sequentially or from patient to patient, indicating the use of documentation software that rephrases sentences to vary their meaning to make them look like they were not generated by computer. For example, the software can change canned notes from "patient feeling slightly better" into a multitude of variations.  
  • Overall greater reimbursement for that provider than with paper records. "If there's higher revenue over the patient population or shifts in levels of service it's a red flag," Bowerman notes.
  • Different notes for the same day of service for records that have been resubmitted. Payers compare the records on hand to those resubmitted to the appeals department. Differences indicate alteration. "It's a way of double checking the system," he says.  

Payers also use speed so that providers don't have time to "improve" their electronic records. "The longer you give a provider, the better the records will look because they've been altered," Bowerman says. "It's best when payers use a search warrant. But plans often can't do that."

How private payers detect EHR-enabled fraud