EHRs and improper billing: Should we worry?

e-healthPhysiciansPolicy and politics
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Concerns are emerging that the adoption of electronic health records is leading to inappropriate increases in billings to payers, including Medicare, and that these higher billings could undermine or even overwhelm any cost savings generated by the digitization of providers. The concerns are legitimate but overall I'm not worried about this phenomenon, at least in the long term.Here are the key issues:

  • It didn't take long for some physicians to figure out that they could essentially use the EHR to cut and paste records from a patient's past visit or even from another patient's records. As a result the record is much more thorough than it would have been otherwise and may describe more billable services than were actually performed.  This practice has been termed "cloning."
  • A second issue --as documented in the Center for Public Integrity's Cracking the Codes-- is that providers have been finding ways to bill Medicare more intensively for the same level of actual services. This has been going on for 10 years or more, but is apparently being accelerated by EHR adoption.

My take is as follows:

  • The first issue is a transient one. Sure, some doctors found a lazy, seemingly clever way to save time and maybe make more money. But this practice is bad medicine and a flat out abuse of the system. To me it's not so different from a doctor who reuses a disposable needle. They should only need to be told once that this is unacceptable. With EHRs it might take a bit of time to work out the norms and protocols to avoid cloning, but it will have to happen. Risk managers will insist on it for one thing. For another, one of the good things about a computer is that it can generate an audit trail. The cutting and pasting can be detected and flagged electronically, if not by the current generation of EHRs then by the next generation of fraud detection software. And patients will be angry if they find out this is happening to their records, and will increasingly vote with their feet.
  • The second issue is only partly a function of the EHR. The bigger issue is the way billing is done. First, if providers can find a way to better document the work they are actually doing, then it's reasonable for them to take advantage of that and bill for whatever's allowable. Being able to fully bill acts an extra incentive for EHR adoption, above and beyond the Meaningful Use incentives. As long as the extra documentation for billing is the result of more robust clinical documentation (of work that is actually performed) then I'm all for it, because that clinical documentation could be useful for quality improvement. Of course, some of the billing is illegitimate, and again should be tracked down and disallowed.
  • Finally, this controversy sheds more light on the limitations of fee-for-service medicine, where doing more things to a patient results in higher pay. If concerns about billing games help accelerate the shift away from fee-for-service then I'm all for it.