The hospitals and doctors that should be most alarmed by last week's warning are those who consistently bill Medicare for the most expensive forms of “evaluation and management” services, because investigators are data-mining Medicare for statistical outliers in E/M services.
But overall, healthcare providers say they expect EHR systems to continue generating more revenue than paper documentation, regardless of the warnings.
Although the systems may be vulnerable to fraud by unscrupulous individuals, users say they also enable physicians to do more work during visits with patients who are presenting with more complex problems in the past. An electronic medical record also allows caregivers to document their work better than before.
“When you roll out an EMR, you are not trying to just replicate what you do on paper. It is really an opportunity for process improvement,” said Dr. Lyle Berkowitz, a primary-care physician and associate chief medical officer of innovation at Chicago's Northwestern Memorial Hospital. “In the past, a busy doctor may not have been able to document everything he could bill for.”
Like others in healthcare, Berkowitz doesn't deny that efficiencies in EHR technology may make traditional “upcoding” fraud easier, as well as the risk of cut-and-paste “cloning” of records. But he thinks authorities should focus on all types of fraud, not only those involving electronic records.
In any case, it's not clear what effect any warning of enhanced government investigation could have, given the high degree of scrutiny already at work.
“We suffer from a plague of auditors,” said Connie Kinsella, vice president of revenue cycle for UW Health, based in Madison, Wis., and includes a physician practice and the 493-bed University of Wisconsin Hospital and Clinics.
UW Health is considered an advanced, “paperless” healthcare provider and has experienced the benefits of more accurate recordkeeping and medical-bill coding. But Kinsella said that even systems and hospitals that are slower to install EHRs will continue to see the need to make the switch, including the improvements to patient safety and system efficiency.
“If I were a small community hospital, I would still recognize that there is value in there,” she said. “Everyone is leaving money on the table.”
There's a difference, however, between coding to accurately capture every service rendered by a doctor and “upcoding” to try to reach more expensive levels of medical bills without regard for what actually happens in an exam room or hospital emergency bay.
Pam Arlotto—president and CEO of Maestro Strategies in Atlanta and author of three books on returns on investment for health IT—said EHR sellers need to understand that it may be dangerous to advertise their wares as being able to increase revenue, as many have.
“I would think that would be a big mistake for a vendor to do,” Arlotto said.
But W. Sanders Pitman, president and CEO of ambulatory-care electronic medical-record maker SuccessEHS in Birmingham, Ala., disagreed. SuccessEHS proclaimed in a Sept. 25 news release that its coding, billing and revenue-cycle management services have helped clients increase their revenue by 10%. But Pitman said such claims are derived from helping doctors earn what they are owed and not by alerting doctors to ways that they could increase their bills.
“We're talking about purposely overcoding, which is not a good thing, versus getting reimbursed for what I do” as a physician, Pitman said. The providers who have the most to fear from the government scrutiny are those whose billing patterns make them stand out statistically from their peers, he said.
According to the letter last week, scrutiny would be directed at bills for evaluation and management, which is the class of ambulatory and primary-care services that can be billed at higher charges at the discretion of physicians depending on how much work was done during the patient visit. Federal officials have been investigating about 1,700 doctors whose charges predominantly tend to come in at the more-expensive end of the scale.
“Everything still should be somewhat on a bell curve,” Pitman said.
The government warning followed two investigative news reports that suggest the increased use of computerized records is driving up healthcare bills, but the issue has been on auditors' radars for years. The CMS has already directed its Recovery Audit Contractors and Medicare Administrative Contractors to probe the accuracy of hospital coding and is initiating more extensive reviews of E/M coding.
Meanwhile, HHS' inspector general's office is in the midst of an investigation slated for release in 2013 regarding the relationship between EHR use and rising bills for evaluation and management services such as hospital emergency department visits, physician office visits and “rounding” visits to hospital inpatients.
The CMS paid $33.5 billion for the 370 million individual E/M services delivered in 2010, accounting for about a third of all services billed through Medicare's Part B for physician services.