In its recent investigation of healthcare billing consultants, the General Accounting Office identified several instances of physicians being taught how to fleece the Medicare and Medicaid systems by overbilling and creating bogus documentation. But the investigation ignored emerging technology--charge-capture and electronic medical records systems--that could facilitate such unscrupulous practices.
"We didn't take a look at EMRs," says William Hamel, GAO assistant director for investigations. "We're looking at what kind of advice is being provided to the community."
A number of charge-capture systems actually flag opportunities to upcode as users enter data, says Tom Giannulli, M.D., a Seattle physician-entrepreneur who has helped develop EMRs. "It became evident to me that the competition's (evaluation and management) code would list the documentation needed to overcode," Giannulli says.
Yet several other charge-capture and EMR vendors say their products guard against overcoding. David Bond, of Cary, N.C.-based A4 Health Systems, says his company's system allows a physician to check off bullet points on a personal digital assistant based on the care delivered. "The system determines the (charge) level, and the doctor can override it."
But this type of manual override feature is exactly why charge-capture systems aren't foolproof, says Charlie Koo, CEO and chairman of Mountain View, Calif.-based iMedica, maker of an EMR and PPM software package.
"That subjective interpretation is where the problem is," Koo says.
Sue Prophet, director of coding policy and compliance at the American Healthcare Information Management Association, says once a charge-capture device is set up to overcode, it repeats the error. She recommends that practices audit their own systems before federal regulators step in.
Even with a full EMR, the coding rules set out by the Centers for Medicare & Medicaid Services--the new name for HCFA--and followed by most private insurers are so complicated that errors virtually are inevitable, says Koo. "The doc has to figure out which subsection his writing fits into," he says. "It's then aggregated with other components (of the patient record) to determine the coding level. It's impossible for the doctor to get it right."
Giannulli says the best way to avoid trouble with electronic charge-capture is to enter the documentation first and generate the billing code later.