The HHS warning was uncharacteristically blunt. In a letter distributed last September, Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder warned five hospital associations against using electronic health records to "game" the billing system. "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," the letter said. "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."
The letter-sent to the American Hospital Association, Federation of American Hospitals, Association of Academic Health Centers, Association of American Medical Colleges and National Association of Public Hospitals and Health Systems-sent a shockwave through the industry. HHS said it would step up monitoring of claims for any inappropriate activity, including "cloning"-or copying and pasting certain portions-of medical records from one visit to another. "We will not tolerate fraud," it said.
The topic of upcoding-the practice of assigning a higher level of service to physician work or a higher degree of severity to a patient diagnosis than is warranted-is a long-time industry discussion point, one that predates electronic health records. Yet, many industry experts contend that while upcoding may happen, it is more a result of complex billing rules than anything else.
But linking EHRs to fraud? That was a charge that many in the industry find hard to swallow. Ironically, these experts say that any increase in reimbursement is not due to fraud, but rather due to the better documentation that EHRs enable. Yes, copy and pasting of records occurs, they acknowledge. Yet the practice by itself is not necessarily borne of malicious intent-which many contend is the litmus test for upcoding-as much as it is maximizing the very technology the government is attempting to incentivize through its meaningful use program. Nonetheless, coding and billing experts cite several steps that providers can take to work toward compliance with the thicket of reimbursement rules.
Perplexed and perturbed
Money Atwal is one industry leader who admits to being both perplexed and perturbed by the HHS letter (CMS did not respond to written questions about the letter). He's well-situated when it comes analyzing the link between EHRs and billing-Atwal serves as regional CFO and CIO for the Hawaii Health Systems Corp., which runs three hospitals, including Hilo Medical Center, a 276-bed facility. The three hospitals receive about 44 percent of their payments from CMS with the remainder coming from several commercial plans. "I'm not surprised that overbilling is being discussed," he says. "At HHS, they just see that Medicare reimbursements are increasing substantially. But you don't need an EHR to game your bills. I would like to see HHS factually support its contention."
Like many of his peers, Atwal cites improved documentation facilitated by EHR technology as driving the increased reimbursement. Essentially, the argument goes, physicians and hospitals alike have long left money on the table by not documenting their work. Once EHRs are implemented, documentation capture-and charge capture by extension-improves, sometimes dramatically.
"Before the EHR, we used Post-It notes and would rely on nurses to manually document what they did," Atwal says. "We missed charges. There was huge variation. Now, with an EHR, it's easier to track. When the nurse hangs an IV bag, we can document the start and stop times. We can alert the nurse they did not chart the bag. In the manual world, we did not even know if IV bags were being given or documented."
Gary Baldwin’s cover story in the February issue of Health Data Management examines the issue of upcoding and whether it results from fraud or better billing practices.
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