EHR Capabilities Can Open the Door to Billing Fraud

Electronic health records are a wonderful advancement in the way we document healthcare. Health records with electronic access are intended to provide interoperability of healthcare documentation between providers, payers, and patients. This allows for healthcare that is more timely, more focused, and more pertinent to the needs of the patient and helps toward the achievement of the industry’s stated goals of safer and less expensive healthcare.

Yes, anyone in the healthcare industry who knows that lowering the cost of healthcare is at the top of the list for most stakeholders—specifically those same players who will implement EHRs: providers, payers, and patients. The federal government is also an important stakeholder because CMS is the largest third-party healthcare payer. The government has also incentivized the implementation of EHRs through the practice of providing increased reimbursement for those who make the switch or withholding a portion of reimbursement for those who do not.

Unfortunately, the same EHRs that are intended decrease healthcare costs have features that, by nature of their electronic capabilities, can lend themselves to fraudulent billing practices—which actually increases the cost of healthcare for everyone concerned. Let’s explore two ways features that may be included in an EHR can enable fraud if used in a way other than intended.

Feature 1: Copy and Paste
Most EHRs will allow a provider to copy and paste information from one part of the record to another. When used correctly this can be a real timesaver. However, many instances have been reported of providers who have copied and pasted the same history and physical information from a previous visit into the documentation for a current visit or even for several successive visits.

Copying and pasting information that is not current can lead to reimbursement that the provider is not entitled to. A good example is reimbursement based on HCCs or hierarchical condition categories. This method of payment affords the provider reimbursement for a set length of time (e.g., 1 year) based on the chronic conditions a patient has and the projected resources it takes to manage those conditions. If the patient has a chronic condition that resolves (for instance chronic kidney disease that no longer exists because the patient had a transplant) but the condition has not been removed from the list of the patient’s current diagnoses because information is being copied and pasted the physician will receive improper reimbursement because he is no longer using the resources needed to manage that condition.

This is a practice that can be easily identified by the medical coder who reviews the record for ICD-9-CM diagnosis and procedure code assignment as the underpinning for billing and reimbursement. If the coder notices inconsistencies in the documented history and physical and the treatment recommended by the clinician, they should alert their supervisor to the possible need for review of the record to avoid the practice of fraudulent billing.

Feature 2: Software That “Corrects Deficiencies”
A recent article in the Fierce EMR newsletter explains that this software suggests to the provider higher levels of coding and their associated additional reimbursement that can be obtained just by clicking a button in the EHR. While, with proper documentation and appropriate medical necessity, this feature can help a provider receive the full reimbursement they are entitled to, this feature can also be a temptation to misrepresent their services by upcoding, leading to increased revenue obtained through fraudulent billing practices.

Again, a provider’s medical coders are the go-to resource to review the complete medical record to ensure that the services billed for are supported by the requisite documentation.

Review FierceEMRs complete article on EHR billing fraud here.

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