Federal EHR Office to Look at Overbilling Allegations

October 19, 2012

In response to intense media scrutiny, the federal agency in charge of promoting electronic health records (EHRs) has ordered a study of how physicians and hospitals may be gaming the technology to overbill Medicare.

Dr. Farzad Mostashari

Farzad Mostashari, MD, the National Coordinator for Health Information Technology, directed an advisory committee to work with medical software vendors and healthcare providers to determine what EHR documentation functions are "over the line," according to a transcript of an October 3 meeting of the committee.

Dr. Mostashari's agency, the Office of the National Coordinator (ONC) for Health Information Technology, is part of the US Department of Health and Human Services (HHS). One prime responsibility of the ONC has been to develop certification standards for the kind of EHRs that physicians must use if they want to earn hefty Medicare and Medicaid bonuses for "meaningful use" of the technology. Those standards dictate that the systems must be able to perform basic chores such as transmitting a prescription to a pharmacy computer, sharing data with another EHR, or creating an audit trail of who did what to the record.

What has made the news, however, are other EHR capabilities said to help physicians pad their Medicare bills. One is the capability of copying or "cloning" chart notes — often without any editing — from a previous patient visit to document the next one. Such a practice can pull forward clinical information that no longer applies and can also make it appear as if the physician deserves higher reimbursement. Some EHRs also automatically alert clinicians to missing pieces of documentation that, if entered, would justify a higher-paying billing code.

The Office of Inspector General (OIG) of HHS announced last year that it would investigate how such EHR wizardry contributes to code inflation for evaluation and management (E/M) services. The OIG released a study earlier this year showing that Medicare spending for E/M services outgrew overall Medicare spending for physician services from 2001 to 2010. Physicians billed higher E/M codes for office visits — fewer 99213s and more 99214s, for example — and every other E/M category. Experts interviewed by Medscape Medical News attributed the trend in part to more accurate documentation, compliments of EHR technology.

In September, an investigative series published by the nonprofit Center for Public Integrity, as well as an article in the New York Times, shone more light on the relationship between EHRs and higher Medicare billing in both inpatient and outpatient settings. In response, HHS and the Department of Justice sent a letter to a number of hospital associations warning that the government would pursue "providers who misuse EHRs." Allegations of EHR-abetted fraud also figured into a recent demand by House Republican leaders that HHS suspend meaningful-use payments until the incentive program undergoes reform.

Skepticism About Coding Prompts

Some leaders in the hospital industry and medicine say that the shift to higher-paying E/M codes does not reflect fraud, by and large, but, rather, better documentation of services that were undercoded in the paper chart past. Dr. Mostashari took that line when he spoke to the Health Information Technology (HIT) Advisory Committee of ONC on October 3.

"It's not clear what here is fraud [and] what's appropriate payment," Dr. Mostashari said. He also reiterated a point made by others that in a fee-for-service system geared toward the volume and intensity of services, EHRs naturally ratchet up billing by dint of more thorough charting.

However, he said it was "incumbent" on the HIT Policy Committee to "look at medical documentation for optimal patient care."

"We know that there's a lot of information that's not...medically necessary for that visit, that encounter," he said. "If it's copied and pasted forward or duplicated, that's not good patient care.

"There may be some practices that are perfectly acceptable, even good, but there may be some things that step over that line. Is it a prompt that says document more to get the higher billing code? That might be over the line. Is it the opportunity to bypass the audit log? Where are there lines that we can draw and provide clarity, whether through certification or through policy?"

Tweaks to EHR software features such as audit logs and provider authentication, Dr. Mostashari added, could help combat fraud.

Whatever conclusions that the HIT Policy Committee comes to on EHR-driven billing, he said, could form the basis of best practices or recommendations for future standards that physicians must meet to earn meaningful-use payments. The Centers for Medicare and Medicaid Services writes the standards for how physicians must use EHRs in daily practice, and ONC writes the standards for the EHR software itself. New standards for the latter conceivably could include more built-in antifraud safeguards.

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