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Joint CMS, DOJ Letter on EHR’s Potential for Billing Fraud; AHA, AAHC Respond

Secretary Sebelius and Attorney General Holder issued a joint letter to the American Hospital Association and four other associations representing hospitals and medical centers, warning of indications that some providers are using electronic health records (EHRs) to upcode the intensity of patient care, clone records, bill for services never provided, and otherwise “game the system, possibly to obtain payments to which [providers] are not entitled.”  The September 24, 2012 letter states the obvious: false documentation is illegal, and health care fraud will not be tolerated.

AHA’s response was immediate and direct.  While acknowledging that the alleged practices described in the letter should not be tolerated, AHA President and CEO Rich Umbdenstock states that "more accurate coding does not necessarily equate with fraud," and notes the ever-increasing complexity of Medicare and Medicaid payment rules. AHA's letter reminds the Secretary and the Attorney General that, despite 11 AHA requests since 2001, CMS has yet to develop national guidelines for the reporting of hospital ED and clinic visits. AHA took the opportunity to point out that, in the face of lack of clearer guidance from CMS, the “flood of new auditing programs, such as Recovery Audit Contractors, Medicare Administrative Contractors, and others, is drowning hospitals with a deluge of redundant audits, unmanageable medical record requests and inappropriate payment details.”  AHA notes that 40% of RACTrac survey denials are appealed with a 75% success rate.  On September 25, 2012, the Association of Academic Health Centers sent a response letter on September 25, 2012, echoing  number of the points in the AHA’s letter.

While one can almost hear the hearty “Amen!” from hospitals reading these responses, the point and opportunity presented here must not be lost.  All stakeholders share the goal of an efficient, high quality health care system that helps providers get billing right the first time.  No one wants fraud to consume resources that are needed to assure continued access to care. CMS, DOJ, and hospitals, alike, have a vested interest in preventing fraud and abuse.  Hopefully, these opening salvos, and the accompanying publicity and public attention, will become a catalyst for joint efforts to utilize EHR to optimize accurate coding, prompt payment, and efficient and fair processes to detect and prevent fraud.


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M. Daria Niewenhous

Member Emerita