Skip to content Skip to navigation

Washington Debrief: Coding Concerns, Enabled by EHRs, Gets OIG’s Wrath

January 13, 2014
by Jeff Smith, Director of Public Policy at CHIME
| Reprints
Jeff Smith, Director of Public Policy at CHIME

Top News

HHS Inspector General Wants More Attention on EHR-Related Fraud

Key Takeaway: The Centers for Medicare & Medicaid Services (CMS) continues to feel pressure over “upcoding” and “cloning” that’s enabled by electronic health records (EHRs), after a Department of Health and Human Services (HHS) watchdog agency issued a report saying CMS and its contractors should do more to prevent fraud.

Next Steps: CMS will likely issue guidance to its payment and program integrity contractors on how to identify inappropriate billing through EHRs; this most certainly will have an impact on provider audits. In anticipation of this, CIOs should consider how well their audit logs are able to authenticate how data are put into an EHR following a patient encounter.

According to a report released last ( week by the HHS Office of Inspector General (OIG), CMS and its contractors aren’t doing enough to combat fraud and abuse by providers who use EHRs to upcode or clone records. Contractors including MACs, ZPICs, and RACs have indicated they do very little to confirm physician electronic signatures or conduct of any reviews of EHRs, the OIG report said. To address this, the OIG recommended that CMS issue formal guidance to its contractors on detecting fraud associated with EHRs and work with contractors to identify best practices and tools for identifying fraud via electronic records, focusing on audit logs as a way to monitor fraud. In response to the report, CMS agreed with the recommendation of more guidance, but questioned whether audit logs would be an “appropriate” source of documentation in “every circumstance.” CMS is working with the ONC to develop tools for determining the authenticity of information in EHRs, CMS Administrator Tavenner said.

Legislation & Politics

SGR Watch: Health IT Amendments Introduced

Key Takeaway: Congress continues to work on a permanent fix for the Sustainable Growth Rate (SGR) formula, which determines physician Medicare reimbursement rates. Congress plans to utilize existing programs – like meaningful use and PQRS – to determine quality and bonus payment levels.

Next Steps: Lawmakers are poised to re-introduce amendments that would define and require interoperability.

While Congress did not find a permanent solution to reinvent the SGR formula in December, they only gave themselves a three-month patch to come up with a solution, as many believe a permanent fix is within reach. Health IT rose to prominence in the SGR debate because Congress acknowledges that the use of HIT reduces healthcare costs and increases care quality. But several lawmakers believe the use of EHRs alone will not maximize healthcare savings if providers cannot exchange information seamlessly to coordinate care. Thus, two amendments proposed recently include interoperability in the SGR fix. One amendment introduced by Sens. John Thune (R-S.D.) and Mike Enzi (R-Wyo.) would require "interoperability to be achieved by 2017 to be [a] meaningful user under the Electronic Health Record Meaningful Use program." Another amendment introduced by Sen. John Cornyn (R-Texas) proposed requiring HHS to adopt standards for interoperability across EHR systems by 2017. These items did not make it into the patch, but send a strong signal as to what awaits health IT if and when a final deal is reached.


CMS Looking for Input on Next Generation ACOs

Key Takeaway: The Centers for Medicare & Medicaid Services (CMS) are seeking input on the evolution of Accountable Care Organization (ACO) initiatives. Specifically, they are interested in feedback on what a second round of applications for the current Pioneer ACO Model should look like, as well as new ACO models that encourage greater care integration and financial accountability.

The five-part questionnaire spans issues such as integrating accountability for Medicare and Medicaid outcomes to questions about designing risk-based contracts with multi-payer ACOs. While most of the more than 30 questions posed by the CMS Request For Information ( concern financial costs and risk-sharing, a handful of questions pertain to EHRs, data capture and quality measurement. The RFI asks, “What are the capabilities of providers in integrating [Medicare and Medicaid] data with electronic health records?” and “How can CMS and other payers focus reporting of quality measures on the most important priorities while minimizing duplication and excess burden?”

If you are involved with a current Pioneer ACO or are considering what it might take to form one, please consider responding ( the RFI by March 1, 2014.