HealthData Management - November 2012

The Department
of Health and
Human Services
has award a new
round of grants
to Arkansas,
Colorado, Ken-
tucky, Massachu-
setts, Minnesota
and the District
of Columbia
as they build
health insur-
ance exchanges
mandated under
the Affordable
Care Act.
States Get
Exchange
Funding

Cabinet-level effort to combat health care fraud and pro-
tect the Medicare trust fund, and we take those responsi-
bilities very seriously.”
The letter emphasizes that officials will take appropri-
ate steps to pursue health care providers who misuse elec-
tronic health records to bill for services never provided.
The enforcers include the Department of Justice, Depart-
ment of Health and Human Services, the FBI, and other law
enforcement agencies. “New tools provided by the health
care law authorize CMS to stop Medicare payments upon
suspicion of fraud and to mine data to detect it in the first
place,” the letter says. “These efforts have contributed to
record-high collections and prosecutions. Prosecutions in
2011 were 75 percent higher than in 2008. That said, we will
continue to escalate our efforts to prevent fraud and pursue
it aggressively when it has occurred.”
The letter did thank providers for their work toward at-
taining quality goals, “which can be better achieved once
all Americans have privacy-protected electronic health re-
cords. As we phase-in electronic health records, though, we
ask for your help in ensuring that these tools are not mis-
used” for illegal billing purposes.

SoMe HeAltH DAtA MANAgeMeNt reADerS Are not pleased with the obama Administration’s warning to hospitals to stop using electronic health records to game the billing system. Here is a sample of comments:

• “I doubt there is any increase in fraud. I haven’t seen
any statements that claim that there actually is, just this
‘warning.’ What is being stated is that payments (costs to
taxpayers) have gone up. This is after the administration
passed the ARRA and the ACA, telling us we would be
grateful when we saw the costs start to drop. So now that
the costs are rising, this allegation of fraud comes out.
How about this ... maybe EHR systems improve a hospi-
tal’s ability to track and get paid for legitimate charges
that might have been missed in their old systems? They
are playing the blame game to try and explain why their
predictions are not coming true.”
•“Health care coding is impossibly complex, and this
complexity prevents physicians from knowing what the
rules for billing and coding are. Medicare
manuals on the topic literally run into the
tens of thousands of pages, and entire pro-
fessions are dedicated to this one very com-
plex (and expensive to implement) part of
health care. Most physicians have only the
most rudimentary knowledge of the 30 or
40 codes they use most often.”
• “As has been Medicare’s fashion in re-
cent years, the penalties levied against phy-
sicians far outweigh the equivalent penal-
ties in other business areas. It is absolutely
correct to state that physicians have, for a
number of years, been consistently under-
coding for their services. The increasing
risk of fraud allegations, the severity of the
fines and the relative ignorance of the bu-
reaucratic web of coding regulations have
conspired to ensure this under-coding has
occurred, and it is a commonly accepted
belief in medicine that this confluence of
factors has not been coincidental. The ‘mir-
acle’ of EMRs has allowed the under-coding
to stop. Complicated algorithms are able to