The issue of overbilling comes into focus on the heels
of a federal warning. But is fraud or better billing practices
driving up reimbursements?
UP, DOWN OR AROUND?
By Gary Baldwin
The HHS warning was uncharacteristically blunt. In a letter distributed last September, Health and Human Services Secretary Kath- leen Sebeliusand Attorney General Eric Holder warned five hospital associations against using electronic health records to “game” the bill-
ing system. “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,” the letter said. “False
documentation of care is not just bad patient care; it’s illegal.
These indications include potential ‘cloning’ of medical records
in order to inflate what providers get paid. There are also reports
that some hospitals may be using electronic health records to fa-
cilitate ‘upcoding’ of the intensity of care or severity of patients’
condition as a means to profit with no commensurate improve-
ment in the quality of care.”
The letter—sent to the American Hospital Association,
Federation of American Hospitals, Association of Academic
Health Centers, Association of American Medical Colleges and
National Association of Public Hospitals and Health Systems—
sent a shockwave through the industry. HHS said it would
step up monitoring of claims for any inappropriate activity,
including “cloning”—or copying and pasting certain portions—
of medical records from one visit to another. “We will not toler-
ate fraud,” it said.
The topic of upcoding—the practice of assigning a higher level
of service to physician work or a higher degree of severity to a patient diagnosis than is warranted—is a long-time industry discussion point, one that predates electronic health records. Yet, many
industry experts contend that while upcoding may happen, it is
more a result of complex billing rules than anything else.
But linking EHRs to fraud? That was a charge that many in the
industry find hard to swallow. Ironically, these experts say that
any increase in reimbursement is not due to fraud, but rather
due to the better documentation that EHRs enable. Yes, copy and
pasting of records occurs, they acknowledge. Yet the practice by
itself is not necessarily borne of malicious intent—which many
contend is the litmus test for upcoding—as much as it is maximizing the very technology the government is attempting to incentiv-ize through its meaningful use program. Nonetheless, coding and
billing experts cite several steps that providers can take to work
toward compliance with the thicket of reimbursement rules.
Perplexed and perturbed
Money Atwal is one industry leader who admits to being both
perplexed and perturbed by the HHS letter (CMS did not respond
to written questions about the letter). He’s well-situated when it
comes analyzing the link between EHRs and billing—Atwal serves
as regional CFO and CIO for the Hawaii Health Systems Corp.,
which runs three hospitals, including Hilo Medical Center, a 276-