Providers May Be Abusing Electronic Billing Procedures, HHS, DOJ Say in Letter

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Providers may be using electronic health record (EHR) technology to engage in illegal Medicare billing practices, according to a letter the departments of Health and Human Services and Justice sent to five hospital associations Sept. 24.

DOJ and HHS said they have become aware of “troubling indications” that some providers may be electronically duplicating patient records to increase Medicare billing.

“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 said.

The letter, signed by HHS Secretary Kathleen Sebelius and Attorney General Eric Holder, also said HHS and DOJ would ramp up efforts to pursue and prosecute any fraud associated with EHRs.

“The Department of Justice, the Department of Health and Human Services, the [Federal Bureau of Investigation], and other law enforcement agencies are monitoring these trends, and will take action where warranted,” the departments said in the letter, which was sent to the American Hospital Association, the Federation of American Hospitals, the Association of Academic Health Centers, the Association of American Medical Colleges, and the National Association of Public Hospitals and Health Systems.

Provider adoption of EHR technology has been on the rise in part due to a Medicare and Medicaid incentive program.

The program was mandated under the Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Reinvestment and Recovery Act (ARRA), to encourage physicians and hospitals to adopt and meaningfully use certified EHR systems to improve care and save costs.

AHA: CMS Needs to Issue Guidelines.

AHA, in a response to the HHS-DOJ letter, said that while it agreed that upcoding and using EHRs to duplicate patient records should not be allowed, the Centers for Medicare & Medicaid Services should provide national guidelines for evaluation and management (E/M) coding.

E/M coding converts a patient-doctor visit into a five-digit Current Procedural Terminology (CPT) code that is then used for billing purposes.

“What's needed is clearer guidance from CMS, not duplicative audits that divert much needed resources from patient care,” AHA President and Chief Executive Officer Richard Umbdenstock said in the letter.

Hospitals face a growing number of auditors, including Recovery Audit Contractors and Medicare Administrative Contractors, he said.

Umbdenstock said that once CMS releases national guidelines, a proposal should be “presented to the AMA's CPT Editorial Panel to create unique CPT codes for hospital reporting of ED [emergency department] and clinic visits based on the national guidelines.”

AHA has made 11 requests to CMS since 2001 to create national guidelines for coding hospital emergency department and clinic visits, Umbdenstock said.

Administration Responsibility.

In a response to BNA, Joel White, executive director of the Health IT NOW Coalition, said Sept. 25 he agreed that national coding guidelines need to be released.

“The AHA response was appropriate,” White said. “The administration shares some responsibility for upgrading coding standards.”

The Health IT Now Coalition represents 65 health information technology organizations and promotes the deployment of health IT solutions.

White also said the administration should do more to leverage existing technologies, such as authenticated biometrics, to protect EHRs from fraud.

Overall, White said he was pleased that the administration was “stepping up to fight EHR fraud” and that the letter will lead to hospitals tightening up their policies surrounding the use of EHRs.

Harry Greenspun, a senior adviser for health care transformation and technology at the Deloitte Center for Health Solutions, told BNA Sept. 25 that while EHRs can facilitate upcoding, they can also help with investigations into possible fraud.

“This should help dampen some criticism of the use of EHRs for upcoding,” Greenspun said. “More importantly, given that as much as 30 percent of health care spending is wasted on unnecessary, inefficient, and uncoordinated care (along with a smaller contribution of fraud), the conversion to electronic health data is essential to control that waste.”

By James Swann  

The HHS-DOJ letter is at The AHA response is at

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