"As leaders in the health care system, our nation's hospitals have been at the forefront of adopting electronic health records for use in coordinating care, improving quality, reducing paperwork, and eliminating duplicative tests," the government says. "Over 55 percent of hospitals have already qualified for incentive payments authorized by Congress to encourage health care providers to adopt and meaningfully use this technology. Used appropriately, electronic health records have the potential to save money and save lives.
According to the letter, there are troubling indications that some providers are using EHR technology to game the system, possibly to obtain payments to which they are not entitled. False documentation of care is not just bad patient care; it's illegal, the letter points out. "These indications include potential 'cloning' of medical records in order to inflate what providers get paid. There are also reports that some hospitals may be using electronic health records to facilitate 'upcoding' of the intensity of care or severity of patients' condition as a means to profit with no commensurate improvement in the quality of care."
The government used the letter to underscore its resolve to ensure payment accuracy and to prevent and prosecute health care fraud, citing dubious documentation practices that may be associated with an EHR. "A patient's care information must be verified individually to ensure accuracy; it cannot be cut and pasted from a different record of the patient, which risks medical errors as well as overpayments," the letter says. "The Centers for Medicare and Medicaid Services is specifically reviewing billing through audits to identify and prevent improperly billing. Additionally, CMS is initiating more extensive medical reviews to ensure that providers are coding evaluation and management services accurately. This includes comparative billing reports that identify outlier facilities. CMS has the authority to address inappropriate increases in coding intensity in its payment rules, and CMS will consider future payment reductions as warranted."
The letter noted that the government will not tolerate health care fraud. "The President initiated in 2009 an unprecedented Cabinet-level effort to combat health care fraud and protect the Medicare trust fund, and we take those responsibilities very seriously."
The letter emphasizes that officials will take appropriate steps to pursue health care providers who misuse electronic health records to bill for services never provided. The enforcers include the Department of Justice, Department of Health and Human Services, the FBI, and other law enforcement agencies. "New tools provided by the health care law authorize CMS to stop Medicare payments upon suspicion of fraud and to mine data to detect it in the first place," the letter says. "These efforts have contributed to record-high collections and prosecutions. Prosecutions in 2011 were 75 percent higher than in 2008. That said, we will continue to escalate our efforts to prevent fraud and pursue it aggressively when it has occurred."
The letter did thank providers for their work toward attaining quality goals, "which can be better achieved once all Americans have privacy-protected electronic health records. As we phase-in electronic health records, though, we ask for your help in ensuring that these tools are not misused" for illegal billing purposes.