While the American Health Information Management Association hasn't traded in its medical records or healthcare information-technology hats to join the antifraud police, the Chicago-based organization has capitalized on its expertise in coding and compliance to snare a nearly half-million-dollar federal grant to study how IT can battle healthcare fraud.
Late last month, HHS' Office of the National Coordinator for Health Information Technology announced it would pay a foundation arm of AHIMA $480,000 to study automated coding software and identify and recommend best practices for the prevention, detection and prosecution of healthcare fraud.
"The purpose of this project is to explore how the use of health information technology can enhance and expand healthcare antifraud activities," according to a news release from David Brailer, the nation's healthcare IT czar. "As the healthcare sector embraces electronic health records to reduce medical errors and improve cost-effective delivery of care, these same technologies have the potential to prevent and detect healthcare fraud."
The grant was awarded to AHIMA's Foundation of Research and Education, which will conduct the best-practices portion of the grant proposal and oversee the work of its subcontractor, the University of Pittsburgh School of Health and Rehabilitation Sciences' Health Information Management Department.
Linda Kloss, executive vice president and chief executive officer of the 50,000-member organization, says AHIMA applied for the grant earlier this year. Kloss says most members aren't directly involved in fraud detection or prevention, but she adds, "We work in the area of coding and preparing the clinical codes that form the basis for submitting claims. We're certainly in the compliance business and have a strong code of ethics relating to the accuracy of claims data submitted by provider organizations."
Kloss says AHIMA has long advocated quality in claims data and has supported the transition from paper to electronic records. "We've already reviewed the current state of the art in coding technology and have been proponents of technology in coding to streamline processes," she says. "We have the capacity to do projects like this. Through our foundation we give grants to do applied research in our field and now are doing that ourselves."
She says the University of Pittsburgh team will produce a report by June 30 on fraud-detecting technologies and some principles for technology developers.
The portion of the grant that AHIMA's foundation will complete is expected by September. The foundation will hire a project director, senior associate and a temporary project staff. They will convene an executive committee composed of stakeholders from payers, providers, billing services and the banking and credit card industries. She says those committee experts are being invited now and will meet for the first time May 24 in Washington.
"The goal is to describe and identify best practices, to enhance the capability of our system and use technology for prospective detection and prevention," she says. "Privacy and fraud are foundational issues and the purpose of this is to be proactive, to look at this in the context of advancing our national healthcare information system."
Kloss says the study will include about a dozen site visits, as well as extensive literature reviews and conversations with experts to produce a report focusing on guiding principles and best practices for employing technology in anti-fraud efforts.
Kirk Nahra, general counsel for the National Health Care Anti-Fraud Association, an organization representing private and government payers, says everyone agrees technology can play a huge role in fighting fraud. But Nahra, a partner in the Washington office of Wiley, Rein & Fielding, says the major impediment now is cost.
Hurdling cost barriers
"The broadest technology approaches from the major players are just very expensive," he says. "The cost of the front-end investment has been very difficult for many companies to get approved. And most products that are good at spotting trends are retrospective -- after the fact. And it's much harder to get that money back after the check's been sent.
"It would be beneficial if the programs could better address fraud prospectively, but then they face trouble from states with prompt payment laws and HIPAA transaction standards," he says.
He also notes that payers have difficulties in aggressively attacking provider fraud because they need to maintain good relations with their provider networks.
"That can be a risky approach," he says.
Bert Forman, an anesthesiologist and founder of a software and antifraud consulting firm, Forensic Health Care Auditors, agrees that technology offers great potential in uncovering healthcare fraud. "Software is a tool, but I don't think it's the major solution," Forman says. "Insight is needed. The human eye and intelligence should not be left out of this process."
Forman, whose company contracts with payers to detect fraud and recover overpayments, says he's not completely convinced that the industry seriously wants to rid itself of fraud.
"They're making money and (fighting) fraud presents a huge headache to them. It's something they've long considered a cost of doing business, something built into the system," Forman says. "It's a pain for them now to explain to shareholders that they've gotten bilked out of millions of dollars."