Stakeholders at a federal hearing expressed skepticism that fraudulent billing practices are happening as a result of the widespread adoption of electronic health records,
"We want to know whether the trend toward severity in illness in the ER is real instead of a result of people gaming the system – that's the big gorilla on the table at this point," said Benjamin Chu, M.D., chairman of the American Hospital Association and regional president of Southern California Kaiser Foundation Health Plans and Hospitals.
The CMS in early May convened a four-hour listening session to hear from providers, EHR vendors and other experts on the issue of "upcoding," whereby hospitals and physicians may intentionally manipulate functions in EHRs to overbill payers for services. About 5,000 people attended the session in person and online, the CMS said.
The issue has come to the fore because of articles in the popular press and a 2012 Office of the Inspector General report, which indicated that 1,700 out of 440,000 physicians nationwide cost Medicare upwards of $100 million in 2010, largely in emergency medicine, family practice and internal medicine.
This is an appalling Catch-22 for physicians.
board chair, American Medical Association
EHRs allow for more precise coding practices, so a rise in codes submitted to payers is not unexpected, said Lisa Gallagher, vice president of technology solutions at HIMSS. With EHRs, "HIMSS members can code more accurately," she said.
Gallagher added that with more accurate coding, there is no increased cost overall to the healthcare system, but rather payers may see a rise in costs that were previously absorbed by providers.
Physicians groups said they are often held hostage by a rigid technology and therefore are forced to use shortcuts available to them in EHR programs that could be perceived as an attempt to game the system.
Documenting a patient encounter on an EHR is "pure torment," said Steven Stack, M.D., board chair of the American Medical Association. "Simply stated, many EHRs are not friendly to the user," Stack said.
Clinicians use templates, macros and copy-and-paste functions to facilitate data entry of patient encounters and improve efficiencies, Stack said, but "all create other perils."
For instance, if electronic charts look too much alike, payers may deny claims. But making the charts different enough to pass muster can take valuable time away from the provider, he said.
"This is an appalling Catch-22 for physicians," Stack said.
Jonathan Blum, deputy administrator and director of the Center for Medicare at the CMS, said the agency doesn't see any evidence of fraud as a result of EHR adoption. He added that it's too early in data collection and analysis for the agency to draw any conclusions.
Blum said the agency wants to ensure its policies are "not creating unintended consequences of those who want to maximize their revenue."
The American Hospital Association released a report stating that sicker, more complex patients are driving up the intensity of emergency department care. Between 2006 and 2010, the average severity of illness for fee-for-service Medicare beneficiaries rose by 9%, according to the AHA.
"There's definitely, in the last decade, a shift in the population," Chu said of Medicare patients. "They are living longer and have a larger disease burden."
Chu and others said they could benefit from national guidelines on coding.
EHR managers agreed that the system isn't perfect, but added that payers and providers share a role in improving it.
"The payment system structure creates incentives to produce documents targeted towards reimbursement rather than clinical relevance," said Sue Bowman, senior director for coding policy and compliance at the American Health Information Management Association.
There's no definitive evidence that upcoding is happening, said Mickey McGlynn, senior director of strategy and operations for Siemens Medical Solutions, Health Services, and chair of the Electronic Health Records Association, representing 40 companies.
The association is finalizing an EHR code of conduct that will include increased information sharing with customers, and it is applying user-centered design methodologies to products, McGlynn said.
"You don't want to throw the baby out with the bathwater, right?" she said.