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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.”

Presidential Candidates Outline Visions for Healthcare in NEJM Articles In dueling articles titled, “Securing the Future of American Health Care,” and “Replacing Obamacare with Real Health Care Reform,” President Obama and Republican presidential nominee Mitt Romney describe their healthcare platforms in pieces for the New England Journal of Medicine.  In articulating his views, President Obama detaileda list of the Affordable Care Act’s high points, including the end of lifetime benefit caps, free preventive care services, permitting young adults to stay on their parents plans through age 26, rebates from insurance companies with excessive administrative costs and new tools to halt Medicare and Medicaid fraud.  He also wrote about lesser-known aspects of the law – better known to this readership – such as the emergence of accountable care organizations, which are testing new delivery systems like bundled payments.  The President also noted that methods to combat medical errors and preventable hospital readmissions are expected to save money and lives in the near-term.

In his rebuttal, Mr. Romney says that “Health care is at once among our nation’s greatest strengths and most serious challenges,” but that “President Obama's 2700-page federal takeover does not solve our problems.”  In recapping his premium support proposal, he said competitive bidding will establish the premiums that insurance plans will charge as they do in Medicare Part D to “effectively” control cost.  The government will provide premiums support “set relative to the competitively bid premiums and made more generous for the poor and the sick than for the wealthy, which ensures that each beneficiary can afford high-quality coverage.  This approach will guarantee senior citizens the financial support and high-quality care they deserve while relying on competition and choice — not bureaucrats — to deliver significant savings.”

The New England Journal of Medicine pieces were short on specific policy details; however, the two presidential nominees will have other chances to get into specifics as three upcoming debates are scheduled between now and Nov. 6.

Medicaid Chief Wants to Hear from Providers It was reported this week by CMS Deputy Administrator and Director of the Center for Medicaid and CHIP Service that the agency would soon reach out to stakeholders to gauge their overall level of satisfaction with the Medicaid program.  Cindy Mann said Medicaid would release request for comments on how applicants, enrollees and providers feel about the program in an effort to establish performance standards for the agency.  It is reported that CMS is finalizing regulations proposed last April that aim to ensure beneficiaries have access to Medicaid providers, and that this would serve as the vehicle to seek more information.  According to one report, CMS will ask providers to comment on billing and payment issues – including whether payments are timely – and also on the ease of the provider enrollment process.  CMS wants to ensure Medicaid is a “welcoming program for providers,” Mann said.

CHIME Unveils New ‘Meaningful Use Stage 2 Resources’ Earlier this week, CHIME created a new resource section of its Advocacy site to provide members with a series of resources, including in-house analysis and important documents released by ONC and CMS in the early days since final rules were released.  Please visit: http://cio-chime.org/advocacy/resources/MeaningfulUseStage2.asp to see such documents as, “CHIME MU Stage 2 and Stage 2 Crosswalk,” and “An Overview of Patient Engagement Measures in MU S2” as well as analysis provided by Health Policy Alternatives, a consulting group in DC that CHIME works with.


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