Electronic health records should help facilitate more accurate billing but, when misused, may actually promote fraud. However, depending on your perspective, EHRs are either the cause or the cure for fraudulent activity.
In a semi-annual report to Congress, the Department of Health and Human Services Office of Inspector General highlights the potential for EHR use to lead to Medicare fraud and abuse. Although EHR technology may make it easier to commit fraud, the Centers for Medicare and Medicaid Services and its contractors have not adjusted their practices for identifying and investigating such fraud, according to OIG.
"Few contractors reviewed EHRs differently from paper medical records. Also, not all contractors reported being able to identify copied language or over-documentation in medical records," says OIG. "Finally, CMS had provided limited guidance to Medicare contractors on EHR fraud vulnerabilities." In addition, auditors disclose that only about one quarter of hospitals have policies on the use of the copy-paste feature in EHR technology, which, if used improperly, could pose a serious fraud vulnerability.
Not surprisingly, EHRs can be easily "cloned," whereby a patient is charged for services not received because the provider found it easy to copy-and-paste a record from a different patient. Also, it is easier for providers to exaggerate the level of care or the severity of a disease by "upcoding, which may involve simply clicking a box to trigger a higher billing charge.
Nevertheless, a recent report prepared by an advisory group for the Agency for Healthcare Research and Quality argues that these kinds of abuses should be readily identified by electronic analysis of EHRs and there is a substantial opportunity for exploiting EHR data to reduce fraud. What is required is a combination of clearly articulated expectations for appropriate billing, training on the appropriate use of EHRs, and EHR data analytics to reduce these potential sources of abuse, the report finds.
Electronic access to health data will make it easier to identify fraudulent activity, according to the advisory group. But little effort is being made to use EHRs to identify and reduce even the simplest of healthcare fraud. "Clear indications of fraud should be easy to identify and simple actions can be taken to eliminate their sources," the report to AHRQ states. "For example, delivery of disease-specific healthcare products to patients who have not been diagnosed with the corresponding disease could be uncovered by matching claims to diagnoses in EHRs."
Further, development of more sophisticated data analytics would allow investigators to uncover more obscure patterns of fraud, concludes the report. Toward that end, the advisory group recommends that collections of de-identified EHR data be made available for researchers to develop strategies and algorithms to uncover subtle patterns indicative of fraud, and to adapt these algorithms to the changing tactics of fraud.
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