Is Your Practice at Risk of Submitting Fraudulent E&M Claims?

EHRs that increase Medicare reimbursement through cloning and “upcoding” templated notes have drawn attention from the highest levels of government—including the Attorney General, HHS Secretary Katherine Sebelius, the Office of Inspector General, RAC auditors, four members of the Senate, and four members of Congress. Collectively, they have instructed various government agencies to aggressively pursue providers who engage in this type of behavior.

Physicians: Is your practice at risk? Here’s what you need to know about the potential misuse of EHRs for E&M claims:

What Could Go Wrong?

  • “Upcoding”: If a provider notes a condition in a point-and-click EHR and that notation generates an E&M code—and the physician did not counsel, advise, treat or prescribe for that condition—it opens up the potential for fraudulent behavior.
  • Automated Coding: Some EHRs automatically assign E&M billing codes to different office visits. This may lead to incorrect coding if particular elements were not actually part of an examination.
  • Cloning: Some EHRs allow patient notes to be duplicated from one visit to the next. This may result in serious compliance issues if the cloned information is incorrect.

What Are the Implications?

  • Audits: CMS has explicitly stated they will focus on expanding RAC audits in 2013 to prevent incorrect billing. Medicare billing practices will also be reviewed more extensively to identify specific providers whose billing for expensive services exceeds the average. Many providers have assumed that the RAC audits apply only to hospitals. However, it was recently announced that RAC audits would be done in ambulatory practices, as well.
  • Prosecution: “Upcoding” is illegal and it leaves healthcare providers open to prosecution for fraud. For example, according to FierceHealthcare, 2 organizations paid more than $10 million to settle fraudulent E&M billing allegations in 2009. Additionally, the U.S. Department of Health and Human Services, along with the Justice Department, indicted 91 people in 2011 for playing a role in Medicare billing fraud.

How Can You Protect Your Practice?

The best way to protect your practice is to use an EHR that does not automatically generate billing codes and does not require the use of templates for documentation. An EHR that allows physicians to document unique, nuanced notes that accurately reflect patient health and the work performed during the exam provides the most protection from an audit and allows for superior patient care.

Related posts:

  1. Why Are You Waiting? 5 Ways an EHR Will Benefit Your Practice Now
  2. Hospital-Subsidized EHR: Will It Work for Your Practice?
  3. Data Exchange: Reaching Beyond the Walls of Your Practice

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