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D.C. Report: EHRs Implicated in Upcoding Scheme

October 3, 2012
by Jeff Smith, Assistant Director of Advocacy at CHIME
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Jeff Smith, Assistant Director of Advocacy at CHIME

EHRs Named as Accomplice in Medicare ‘Upcoding’ Practice The subject of electronic health records, and the billions of dollars set aside to digitize the country, made national headlines this week – and not in a way that most proponents of health IT would have liked.  Stemming from two independent analyses, headlines in The New York Times and the Washington Post detailed how greater use of electronic records might be making it easier for hospitals and doctors to submit erroneous payment claims.  According to the Times analysis, “hospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier, at least in part by changing the billing codes they assign to patients in emergency rooms,” in a practice called “upcoding.”  The report also went on to describe a practice called “cloning,” where one patient’s visit history is duplicated, or parts are cut and pasted, for multiple patient visits.  These reports led HHS Secretary Kathleen Sebelius and Attorney General Eric Holder to issue a joint letter to five of the nation’s leading hospital associations, telling them of “troubling indications” that providers are using EHRs to engage in such practices.  The letter went on to say, “We will not tolerate healthcare fraud,” and it asked the hospital associations for their help in “ensuring that [EHRs] are not misused or abused.”

The five associations, including the AHA, FAH, AAHC, AAMC and NAPHHS all responded with letters of their own within 48-hours, reaffirming their commitment to fight fraud and abuse, but also explaining how EHRs allow providers to more accurately bill for the care they deliver.  “It’s critically important to recognize that more accurate documentation and coding does not necessarily equate with fraud,” the AHA letter said.  “…[W]e believe that any changes in coding reflect the fact that EHRs are enabling the development of more complete data sets regarding patient care and that these changes generally do not represent instances of inappropriate coding as suggested,” the FAH letter agreed.  Additionally, many respondents reiterated past calls for CMS to develop national guidelines for hospital ED and clinical visits.

Washington insiders are now suggesting that the increased exposure and national limelight on the issue could lead to congressional action.  Of particular interest to Congress is the estimated amount of overpayments attributable to upcoding – especially as offsets for an extension of the “doc fix.” However, with Congress out of session and in election mode for the next seven weeks, Washington observers believe that it is unlikely any proposals on upcoding could solidify quickly, and also say that staff will continue to monitor the situation.

Congress and Federal Agencies Make Moves on mHealth This week, Silicon Valley Representative Mike Honda (D-Calif.) pitched a bill that would create an Office of Mobile Health in the Food and Drug Administration.  Rep. Honda plans to introduce the Healthcare Innovation and Marketplace Technologies Act (HIMTA) that would “provide recommendations on mobile health application issues.  It would also create a mobile health developer support program at the Department of Health and Human Services to help app developers make sure they are operating within privacy regulations, including the federal law HIPAA that sets privacy standards.”  The current regulatory process proves cumbersome for small mobile start-ups, Rep. Honda suggested, because the process to approval is complicated and accompanied by long wait times.  This announcement comes before FDA releases a final regulation that requires approval for apps that make medical claims.

On a similar wavelength, the Federal Communications Commission (FCC) created a new position to manage their healthcare initiatives, such as their recent announcement of the Medical Body Area Networks (MBANs) that will allow physicians to remotely monitor patients.  Once the MBAN system is in place, the FCC plans to encourage private industry to develop applications for monitoring patients remotely.  An article in National Journal’s Tech Daily Dose says, “These actions are among the first concrete results of the mHealth Task Force, which was launched in June as an outgrowth of an FCC meeting involving technology companies, physicians, hospital administrators, and government officials.”