Problems prevalent in existing EHR systems include:
- Option to copy and forward healthcare data.
- Documentation populating fields on a template allow the data to be generated indicating all systems reviewed and normal. However, this indication may come even when all systems have not been reviewed, and results have not been normal.
Following the identification of an increase in higher level CPT codes for E/M services with providers who used an EHR in their practices, CMS alerted AMA (American Medical Association) to conduct audits in 15 states, first in Region C. Providers have to submit medical records if the RAC or recovery audit contractor requests them. The instruction is to submit the medical records via ESMD (electronic submission of medical data). But faxed records, paper records and those on CD/DVD are also accepted. Cloning detection software is expected to efficiently detect instances of cut/copy and paste. Moreover, with more advancements in EHR systems and data analytics, RACs can easily locate cloned records.
Medicare beneficiaries and providers may challenge the RAC auditor’s decision and appeal decisions related to claims for healthcare services. The appeal process is four-tiered, comprising level 1 administered by the CMS Medicare Administrative Contractor, level 2 by CMS Qualified Independent Contractors, level 3 by Administrative Law Judges or ALJs and level 4 by the Medicare Appeals Council. A November 2012 report conducted by OIG (Improvements Are Needed at the Administrative Judge Level of Medicare Appeals) saw many ALJs explaining that they decide against appellants if they suspect fraud and there is lack of credible evidence, or if the medical records look suspiciously similar. Following this, OIG has identified “Identity Fraud and Abuse Vulnerabilities in the EHR systems” and “Identical Documentation across Services” in its Work Plan for 2013.
At present, there are several database and data analytical and mining tools that are utilized for identifying fraudulent medical billing and coding – Fraud Prevention System, One Program Integrity, Next Generation Desktop, SAS statistical programming software, CMS Integrated Data Repository (IDR) and the Command Center, according to the Healthcare Fraud and Abuse Control Program Annual Report for Fiscal Year 2012 that was published by HHS and the Department of Justice. Auditors may also start using the plagiarism detection software mentioned at the outset to detect fraud in medical records.
What Precautions Can Providers Take?
To prevent compliance issues, providers can:
- Make it a point to review EHR documentation and evaluate the documentation style
- Ensure that the documentation adheres to Medicare Contractor Policies
- Maintain a proactive attitude and review the use of carry forward documentation
Cloning issues and faulty medical coding may very often be inadvertent but providers still have to pay a heavy price for this. It is the responsibility of providers to take all steps needed to face the challenges posed by electronic documentation requirements, both from the point of view of patient care and from that of compliance and due reimbursement.