EHR Fraud, Abuse Targeted in OIG Survey

October 25, 2012

The fraud squad of the US Department of Health and Human Services (HHS) has mailed out a 54-question survey that digs into widespread allegations of Medicare overbilling committed with electronic health records (EHRs).

The Office of Inspector General (OIG) sent the survey recently to hospitals that received a federal bonus from January 1, 2011, to March 31, 2012, for meaningful use of EHRs, as reported by the American Hospital Association on its Web site. Most of the questions focus on data security features of the hospital's EHR system, but several pertain to how clinicians document and code their services — one more warning of an impending crackdown on EHR abuse.

The survey asks hospitals whether they have a policy on the use of EHR functions that allow providers to cut and paste or "clone" chart notes from a previous patient encounter to document the next one. If the older cloned information is not edited to ensure that it still applies, it may introduce clinical errors into the patient record as well as support the choice of a higher-paying billing code — known as upcoding — that is not warranted.

The OIG survey also asks whether the hospital uses or plans to use computer-assisted coding. Those questions are telling because HHS is skeptical of coding software that not only calculates a billing code — in particular, those for evaluation and management (E/M) services — based on the documentation but also prompts providers to add more information to earn a higher-paying code.

The OIG said in the survey that it was posing the questions as part of "a study on fraud and abuse safeguards in EHRs." Such a study should come as no surprise: The office's published work plans for both fiscal 2012 and fiscal 2013 state that it would "identify fraud and abuse vulnerabilities" in EHRs with an eye to publishing a report.

The work plans for both years also announced that OIG would study how EHR technology inflates billing for E/M services in particular. The office referred to chart cloning when it noted "an increased frequency of medical records with identical documentation across services." An OIG study released earlier this year showed that Medicare spending for E/M services outgrew overall Medicare spending for physician services from 2001 to 2010.

In September, the nonprofit Center for Public Integrity and the New York Times published articles that detailed how EHRs can pad Medicare bills for E/M services. In turn, HHS and the Department of Justice warned several hospital associations in a letter that they would prosecute such high-tech fraud. The HHS office in charge of promoting EHR use and setting standards for the technology said it would determine what documentation and coding functions were "over the line."

"It Feels Like Whiplash"

Hospitals and physicians generally have responded to the allegations of EHR-abetted overbilling by saying that the software allows them to more accurately document services that were underbilled in an age of sketchy paper records.

At the same time, healthcare professionals grumble that they are being hassled for using the very technology that the federal government has encouraged them to adopt through incentive payments.

"It feels like whiplash," said Pam McNutt, senior vice president and chief information officer for Methodist Health System in Dallas, Texas, which received the survey.

Adding to the whiplash, said McNutt, is ICD-10, a new, more voluminous and more complex set of diagnostic codes that takes effect October 2014. McNutt said this successor to ICD-9 will require more granular or detailed documentation of patient encounters to support the choice of diagnostic codes, which figure into the choice of billing codes. Hospitals such as hers are under the gun to use software tools to capture every clinical jot and tittle.

"There's nothing wrong with making sure your documentation is accurate and your coding is accurate," said McNutt, who sits on the policy steering committee of the College of Healthcare Information Management Executives. "We're not doing this to upcode."

Hospitals that received the OIG survey were asked to submit their answers by Friday, October 26. McNutt said the letter accompanying her survey was dated October 11.