Protect yourself against fraudulent EHR documentation

Protect yourself against fraudulent EHR documentation

As physicians, we know that no matter what care we provide, Medicare and private payers are going to do what they can to reduce payouts. For the health of the nation, healthcare spending simply cannot continue on its current trajectory. Reform measures such as accountable care organizations, bundled payments and penalties for potentially preventable complications and readmissions may help reduce expenditures, but with healthcare representing such a large and continually growing proportion of this country’s GDP, additional steps are necessary.

So, what does all of this have to do with electronic medical records?

The intent of EHRs, of course, is to improve patient care and ultimately reduce costs—ergo, the government’s push for providers to transition from paper documentation to EHRs. The downside is that certain EHR functionality makes it easier for errors—whether intentional or not—to occur, and on a considerably larger scale.

Many, if not most, EHR systems implement macros, which allow users to generate a lot of documentation with one click. This practice, called charting by exception, can save a significant amount of time and makes using tedious systems less painful. But, the user must then carefully amend the record to make it accurate for that particular patient and visit or run the risk of fraudulent documentation. For some systems, macros are necessary to avoid productivity impacts from using EHRs. Many systems also feature functionality that permits the automatic population of certain parts of a patient’s record without provider review or without relevance to that visit, a practice known as chart cloning. As a result, documentation can be produced for services that were not actually provided. As you can see, upcoding is possible with both of these features.

Soon after The New York Times published its front-page article in September about the substantial increase in Medicare reimbursements for many hospitals after EHR implementation, HHS Secretary Kathleen Sebelius and U.S. Attorney General Eric Holder put hospitals on notice that instances of fraudulent behavior in connection with EHRs would be subject to criminal charges—and that steps would be taken to ferret out this type of fraud.

You could be vulnerable to suspicion of fraud if your EHR automatically generates codes inconsistent with your existing level of documentation—if your EHR suggests how to obtain higher reimbursement fees or how to generate higher codes, or if your EHR makes a patient’s chart more robust than what actually occurred during the patient visit.

As a practicing emergency department physician, I understand why doctors embrace macros and similar EHR features that reduce time spent on documentation and make their job seemingly so much easier. But, these benefits are not without risk, and the risk appears to be escalating as the federal government promises to begin taking a closer look.

You can protect yourself against the risk of improper coding by being familiar with the features of your EHR and how to use them properly. Not all EHR systems rely on cloning or auto-population to maintain clinician efficiency. Some EHRs are structured to avoid the potential for upcoding by enabling providers to capture the elements that populate the patient’s chart at the point of care, without impeding productivity.

With CMS and other payers looking for any good reason to decrease payments, and with the threat of fraud charges now hanging over our heads, it’s more important than ever to make sure that documentation is as accurate as we can make it—which is, after all, a primary goal of EHRs. Like it or not, this technology has become an integral part of the practice of medicine. Bear in mind, though, that it’s merely a tool. How you use it is up to you.

Robert Hitchcock is an emergency physician and Chief Medical Informatics Officer, T-System, Inc.

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  • Earl Smith

    I have used a variety of EMRs over the last few years, and I think the VA’s CPRS is the best and most user-friendly. I also wish my hospital would allow use of DragonSpeak, because typing is slower than speaking for most of us. My residents often click on the “findings” suggested by our software package, instead of free-texting what their exam shows them. It’s frustrating.

    • buzzkiller

      Dragon doesn’t work for me. Lots of errors and it seems to close at inopportune times. It works for some of the docs, however. We’re very fortunate in our practice in that we still have a transcriptionist who jockeys our ehr, but most docs don’t have that luxury.

  • southerndoc1

    “The intent of EHRs, of course, is to improve patient care and ultimately reduce costs . . . uh, . . . no.

    • Bob Edsall

      It’s probably not too naive to say that that is the intent. It’s the current reality that makes it seem unlikely. Twenty years from now (if you can wait that long!) EHRs may even achieve the intent.

  • Jill Mckenzie

    I have no trust at all in records .I was in a hospital bed and a nurse handed ,me a form..I filled it out and signed it. Just before disappeared…had to be filled out again..I saw the ‘nurse’ put it in my folder..they are outside on the door when a patient walks in and is in the room..or at the front desk…

  • Mary_Pat_Whaley

    It’s important that EMR documentation and the services billed based on that documentation be evaluated regularly to make sure they match. In the case of physician services (professional fees), physicians should make sure a qualified coder or auditor that is internal or external to the organization

  • Larry Sheldon

    As an apparently uncommonly attentive patient (my only connection with the medical system) I think the headline caution applies to me in spades.

    In no particular order:

    My in-clinic time has about doubled by my face time is miniscule (butt time has skyrocketed).

    My cardiologist for some years has quit.

    The ophthalmologist in post-op erenewed a synthroid prescription at a dosage I have not used for some time,

    The record showed that I had been diagnosed with dementia (bad news, I am (or was) a CDL holder). No supporting evidence recorded,

    The record showed that I had been diagnosed with osteoporosis (bad news, I am (or was) a CDL holder and had not reported that to the DOT Medical Examiner). No supporting evidence recorded,

    The record showed that I had been diagnosed with diabetes myelitis (bad news, I am (or was) a CDL holder and had not reported that to the DOT Medical Examiner. If it said I was insulin dependent I would not allowed to drive again). No supporting evidence recorded,

  • Randall Oates, MD

    I am a big fan of EHR, and after more than 2 decades of focused
    tweaking, I have discovered that it is best if physicians perform little
    to no data entry directly and should avoid templated-cloned input as much as is possible. How to do this without forcing them through a bunch of often senseless pick lists? They should only need to sign off on the
    documentation on their iPad (or similar mobile device) what has been
    entered in real time by a remotely located super-scribe who is also
    performing all information navigation and the queuing-up of
    administrivia for the doc to sign off as well. This form of Medical Care
    Coordination will become increasingly necessary. Unfortunately,
    obsolete EHR workflows designed to turn doctors into distracted data
    trolls and clinician’s/administrater’s old habits of thinking that docs have to to be the record clerks are difficult challenges.
    Let the patient and the practice team pre-enter the structured information that is then reviewed/edited by the Medical Care Coordinator, with real time clinician gudance-monitoring when the doctor is actually with the patient (and focused on the patient rather than charting).

    This gives the joy of practice back and ends docs having homework.

  • Docbart

    Let’s face it- EHR is a productivity killer for physicians. If “macros are necessary to avoid productivity impacts from using EHRs”, then the system is fundamentally flawed.
    When I have to read “notes” generated this way, the listing of diagnoses and codes, cloned medication list and lab results (with little or no useful narrative)looks more like a packing slip from a delivery carton than it does like a medical chart note. Very sad that any physician would affix even an electronic signature to such a worthless piece of work.
    Nancy Reagan had it right- Just say no.

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