“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. 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.
“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.”
What is being stated is that payments (costs to taxpayers) have gone up. This is after the administration passed the ARRA and the ACA, telling us we would be grateful when we saw the costs start to drop.
So now that the costs are rising, this allegation of fraud comes out. This seems very similar to the allegations that blamed a youtube video for the attack in Libya.
How about this... maybe EMR and EHR systems improve a hospital's ability to track and get paid for legitimate charges that might have been missed in their old systems?? IMO they are playing the blame game to try and explain why their predictions are not coming true.
As has been medicare's fashion in recent years, the penalties levied against physicians far outweigh the equivalent penalties in other business areas. At $10,000 _per violation_, it is absolutely correct to state that physicians have, for a number of years, been consistently undercoding for their services. The increasing risk of fraud allegations, the severity of the fines and the relative ignorance of the bureaucratic web of coding regulations have conspired to ensure this undercoding has occurred, and it is a commonly accepted belief in medicine that this confluence of factors has not been coincidental.
The "miracle" of EMRs has allowed the undercoding to stop. Complicated algorithms are able to match the complicated rules, and physicians are able to confidently bill for the actual services they provide. This is a very different scenario compared to when, just a few years ago, the "tie" that resulted from the combination of complexity and ignorance always went to the payers out of fear of the excessively punitive consequences of error. The resultant increase in coding costs merely represents another in a very long string of unpleasant unintended consequences resulting from government's incessant attempts to take over and control the health care of every American.
To be sure, there always have been and always will be individuals and companies which game the system, just as occurs in every other government endeavor from office supplies acquisition to defense contracting. But the government's justification of their fraud claims on the basis of recent increases in enforcement actions are themselves fraudulent. Strip out narcotic "pill mills", non-physician providers and DME scams, and you find that physicians today are as honest as they have been in the past and, by and large, that's pretty darned honest.
Obamacare is, as has been predicted, going to be proven an economic disaster, and it appears that will happen even sooner than the original fairly pessimistic forecasts. CMS is afraid that they will (rightfully) be made the scapegoat as costs continue to skyrocket, and the current anti-fraud stance is as much (if not more) about positioning for failure as it is about any real concern over rising costs. The government has designed the "system" of conflicting rules and confounding complexity which we call healthcare, but Sibellius and her co-conspirators don't seem willing to either accept responsibility for the consequences nor to have any willingness to reverse course and stop the regulatory steamroller. It is deliciously ironic that they now find themselves in this position, and that we have EMRs to thank for it.