Monitors: Push for electronic health records overlooks potential fraud

The federal government has paid more than $22.5 billion in incentives to doctors and hospitals to switch from paper to electronic health records, but a new report from an oversight group says the push to adopt the technology has omitted proper protections against overbilling or outright fraud.

The report (PDF), from the Office of the Inspector General (OIG) of the Department of Health and Human Services, says that the government’s encouragement of electronic health records, or EHRs, has not accounted for certain technological tactics that could enable doctors or hospitals to inflate billing costs on their Medicare claims.

“Health care providers can use EHR software features that may mask true authorship of the medical record and distort information in the record to inflate health care claims,” the report said.

Specifically, claims reviewers from the Centers for Medicare & Medicaid Services (CMS), charged with monitoring them for fraud, were polled by the OIG. They reported that they were not reviewing electronic records any differently from paper records. And they did not often use audit functions on EHR that would allow them to see timestamps of when changes are made to the records and who made them, a potential means of recognizing overbilling.

What’s more, the CMS employees largely were not able to recognize the use of copy-paste, a commonly-used function that can replicate information from health records to save doctors from needless repetition. But copy-paste can also be used to inflate billing or medical services, a practice the report called “cloning.”  

“Experts in health information technology caution that EHR technology can make it easier to commit fraud,” the report said. It highlighted a lack of guidance from CMS for its employees and contractors who review electronic health records, and the report recommended that CMS direct them to use the available auditing technology.

In response to the report, CMS said in a release that it was "committed to preventing fraud, waste and abuse in EHRs" and that it "recognizes that additional guidance is needed and intends to work with its contractors for the development of effective guidance and tools in the effort to detect fraud vulnerabilities."

The impetus for doctors and hospitals to start keeping their records in electronic form came from the  Health Information and Technology for Economic and Clinical Health Act, or HITECH Act, a 2009 law that paid incentives to doctors and hospitals for what the CMS calls “meaningful use” of EHRs.

In 2015, the government will begin penalizing them with a 1 percent fee on Medicare payments if they don’t use EHRs, a fine that will increase to 3 percent by 2018.

Wednesday’s OIG report said CMS estimated that health care fraud cost the government between $75 billion and $250 billion in 2009, the latest year for which data is available.

The report follows a separate report OIG released last month showing that three-quarters of hospitals it surveyed didn’t have any protocols covering the copy-paste functions on electronic health records.

In 2012, HHS Secretary Kathleen Sebelius and Attorney General Eric Holder wrote a letter to five major hospital associations warning about the “cloning” of medical records in order to inflate what providers are paid. “There are troubling indications that some providers are using this technology to game the system, possibly to obtain payments to which they are not entitled. False documentation of care is not just bad patient care; it’s illegal,” the letter said.

Around 30 to 40 percent of doctors in the United States are now using EHRs, and their use has tripled since 2009 as a result of the incentive program, said Michelle Dougherty, director of research and development at the American Health Information Management Association (AHIMA).  

Still, the transition to electronic records has meant that some doctors and hospitals make technology-related errors, such as computerized forms that auto-populate with the click of a single checkmark.

“Electronic health records and technology have created a whole new road, and those rules of the road aren’t clear,” Dougherty said. “The implications and ramifications of some of these practices aren’t well understood.”

Other health care experts think that the government is forcing the change to EHRs too quickly, and that hospitals don’t necessarily have the IT manpower to safely use EHRs yet. “As we move into EHRs, there is some new terrain here and they’re being deployed rapidly. The federal government is absolutely pushing hospitals to move more quickly” in adopting them, said Chantal Worzala, director of policy at the American Hospital Association.

“Hospitals take extraordinarily seriously their obligations of properly billing their services, and there are a lot of program integrity efforts under way,” she said. However, “I would say that hospitals have long experience in appreciating the need for testing before going live.”