"However, there are troubling indications that some providers are using this 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. 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.
"This letter underscores our resolve to ensure payment accuracy and to prevent and prosecute health care fraud. 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 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.
"We 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.
"Law enforcement will take appropriate steps to pursue health care providers who misuse electronic health records to bill for services never provided. The Department of Justice, Department of Health and Human Services, the FBI, and other law enforcement agencies are monitoring these trends, and will take action where warranted. 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. 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 nation's hospitals share our goal of a health system that offers high quality, affordable care. We thank you for your relentless work toward this goal which can be better achieved once all Americans have privacy-protected electronic health records. The health information technology incentive program promotes electronic health records that go beyond documentation and billing and towards meaningful use as a foundation for new payment and delivery models. The Affordable Care Act has accelerated the spread of such models like accountable care organizations, patient-centered homes, and value-based purchasing which shift the incentives away from volume and towards value. As we phase-in electronic health records, though, we ask for your help in ensuring that these tools are not misused or abused.
THE IMPACT OF ACOs
What happens to provider billing under accountable care? In some models, payments would no longer be based on fee-for-service, but rather outcomes. Some industry observers think that as the industry embraces the new payment model, issues of overcoding and overbilling will begin to recede. "Coding is entirely way too complex," says Rita Numerof, a St. Louis-based industry analyst. "Physicians often wind up under-coding. They can manage complex problems, but they're nervous about coding for an extended visit. They don't want to be identified by an insurance company as an outlier. Then all their invoices would be held. So they rationalize and eat the charge, which is not fair for doctors doing the right thing."
Numerof calls for wholesale changes in the way the industry reimburses. "We need to get to a different payment system. We can focus on bundled payment and get away from the minutia of a coding system that is becoming more complex and less relevant." The caveat? Numerof contends that for any reimbursement system to succeed in holding down costs, consumers must have a bigger economic stake in their own outcomes and in the quality of services rendered. As such, consumers would be positioned to be a "watch dog" over health care outlays.
Other analysts are less enthusiastic about accountable care-at least as far as its ability to simplify billing. Bundled payment models are an unknown, says Deborah Robb, director, physician services, Trust HCS, which offers coding consulting and training. "Would the same amount of documentation be required or will it be different?" she asks. "If we see one note that has been copy and pasted, would you take the money back even though the procedure was done correctly?"
However industry payment models unfold, documentation and coding will remain a big industry bone of contention in the years ahead, says Ed Hock, senior director, revenue cycle solutions, at Washington, D.C.-based The Advisory Board, a research and services firm. "It won't get any easier as we get into ICD-10," he says, referencing the forthcoming coding and classification system set to come online in 2014. The new coding system includes far more granularity than its predecessor, ICD-9, and will thus require even more detailed documentation from physicians.
As far as upcoding goes, Hock stands by the integrity of the industry. "The vast majority is doing the right thing by coding the care actually provided. You do need to educate physicians to document accurately about what is actually happening."