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The paradox of politics and coding health care procedures

CHICAGO – A few weeks ago, a New York Times piece raised concerns about how EHR systems can be used to game payer reimbursements through “upcoding” health care procedures, or exaggerating the amount of care a patient receives. Attorney General Eric Holder and HHS Secretary Kathleen Sebelius fired off a warning, a couple days later, to CMS providers that they will be scrutinized – whether it was related to the article or not, we’ll never know. Then, the providers responded; it’s all neatly summarized here.

Here at the American Health Information Management Association (AHIMA) Conference, that sequence of events weighs heavily on the minds of vendors and health care HIM managers alike. Implementing an EHR is a complicated task. It’s also difficult getting all involved parties to use EHR properly and getting physicians, HIM managers, IT staff and billing departments to work as well as they did on paper.

More accurate coding and billing results from EHR data, as it turns out. Health care providers will be reimbursed more thanks to electronic systems. That is, unless providers choose to deliberately downcode procedures so as not to draw attention to themselves.  They do this to avoid getting caught in CMS’s analytics web set up for fraud and abuse detection – which, multiple parties have told me on the show floor, is a standard operating procedure many providers have practiced for years.

This isn’t cheating; it’s just acting upon more accurate data.

Add in cheats who deliberately upcode to defraud payers, and this technology suddenly looks like an expensive boondoggle to people outside the health care universe. The technology becomes the bogeyman. The software and its funding by both the Bush and Obama administrations is the problem to people who don’t quite get the yin and yang of payers and providers. It’s also a talking point on the presidential campaign trail and more fodder for the wild-eyed television talking heads on the right and left.

Ugh. HIM managers, vendors and IT folks feel caught in the crossfire, when they’re just trying to do their jobs. And they are. It’s like blaming a screwdriver for a house being burglarized. Or the coat hanger for a car getting stolen. EHRs aren’t the root of the problem – and eventually, all this data aggregation and analytics will pay off for accountable care organizations and reduce costs in the long run. Getting there will cost time and money, and apparently, political capital too.

In the coming days, we’ll break down this issue in depth. It will probably be the start of a long saga to play out over the next few years, no matter which presidential candidate prevails in November.

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The paradox of politics and coding health care procedures http://t.co/9g1fbMhE #AHIMACon12 #EHR #HealthIT #ICD10
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The paradox of politics and coding health care procedures http://t.co/bJ5WnS24
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The paradox of politics and coding health care procedures http://t.co/9g1fbMhE #AHIMACon12 #EHR #HealthIT #ICD10
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The paradox of politics and coding health care procedures http://t.co/9YEGLBnr #ICD10
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