Fear is riding in her shopping cart as Tammy Pon, M.D. searches for the right electronic patient records system.
Pon, a family practitioner and assistant professor at St. Paul Medical Center in Dallas, was at a trade show urgently looking for an EPR, preferably one that has HCFA's upcoming, complicated Medicare clinical documentation requirements already programmed into it.
"It's very important I get one," Pon said, reflecting general physician concern about facing legal action stemming from billing fraud. "I don't want to go to jail."
HCFA's proposed changes in its evaluation and management guidelines, coupled with its newly aggressive pursuit of Medicare fraud, have created a greater demand for EPR systems than most vendors have ever seen. And they're more than willing to serve as doctors' stay-out-of-jail cards -- for a price.
The proposed E&M guidelines are too complicated for doctors to memorize, so many companies have programmed, or are in the process of programming, the guidelines into their EPR computers. Others are waiting until the E&M requirements are finalized. HCFA was scheduled to implement the guidelines July 1, but the implementation date has been postponed indefinitely as a result of continual physician complaints (see May 1998, page 60). When final, the requirements will detail how patient visits must be documented for appropriate reimbursement.
Many vendors at the Toward an Electronic Patient Record conference, held May 9-16 in San Antonio, were disappointed by the delay.
From a marketing standpoint, it would be better if the guidelines had been approved by now, said Renald St. Arneault, M.D., president of Montreal-based Purkinje.
"The delay took away the panic about timing," said Carol Owen, senior product manager at Maitland, Fla.-based Visteon Corp. "But it hasn't taken the attention away. There is still a great deal of fear (among doctors about fraud). This change is going to happen."
EPR systems that include the HCFA guidelines typically work in a couple of ways. One is by automatically tying a clinical record to a billing system that records the correct reimbursement level of the particular treatment. Or, the system merely can include the regulations as a separate file that physicians consult when they need to double-check the codes they have assigned.
But Lernout & Hauspie, a Belgian software company, is developing a more sophisticated system. This summer it plans to release through the Medquist transcription company a product that would tell doctors what additional documentation they would need to raise a treatment's reimbursement level, making it more lucrative.
The company's product manager, David Owen, emphasized the program does not encourage upcoding. Instead, it merely offers suggestions to physicians who might be coding their patient visits too low, which Pon says is a problem with her residents.
"We don't assign a code," Owen said. "We state that our software believes the document will support (a certain level) of coding."
The option of having that sort of information on an EPR will stoke interest among physicians who, until now, have found such systems too expensive and cumbersome, said Russell Sachs, M.D., a senior management consultant at Southfield, Mich.-based Superior Consultant Co.
However, despite physician demand, most vendors are waiting to actually add the new E&M guidelines to their EPR systems. With the HCFA regulations in flux, they figure there's no point in incorporating guidelines that soon will change.
Also, Sachs says, some companies won't add the E&M guidelines until others do.
"It's hard to get a vendor to commit to a specific function change because the vendor has limited resources," Sachs says. "Vendors try to keep up with the Joneses. If someone else doesn't have it, it's not on the top of the list."
Many vendors say it would take months to revise their EPR systems if they were to add the E&M guidelines. And physicians say they understand it doesn't make sense to include E&M information before HCFA approves it.
"It's a game of cat-and-mouse," Owen said. "The fact of the matter is, no one knows what the regulations will look like."
But everyone knows that once the guidelines are approved, they must be followed to the letter. In 1997, Medicare, levied $1 billion in fraud-related fines and used some of those funds to beef up investigations by the inspector general of the Department of Health and Human Services. The crackdown makes it clear to physicians why it may be costly not to have an EPR with the HCFA guidelines included.