DOJ & HHS: Stop abusing electronic record technology for fraudulent Medicare billing

The Department of Justice and the Department of Health and Human Services have issued a weighty warning to hospitals: We’re watching you.

The September 24 letter, co-signed by U.S. Attorney General Eric Holder and HHS Secretary Kathleen Sebelius, was sent to five of the country’s most influential hospital organizations: The American Hospital Association, the Association of Academic Health Centers, the National Association of Public Hospitals and Health Systems, the Federation of American Hospitals and the Association of American Medical Colleges.

Recent study data and swirling publicity over billions in fradulent Medicare claims appear to have triggered the admonition, which warns providers not to misuse electronic medical record technology to cheat the system.

The Holder/Sebelius letter centers on electronic medical record systems, noting that “there are troubling indications that some providers are using this technology to game the system, possibly to obtain payments to which they are not entitled. False documentation of care is not just bad patient care; it’s illegal.”

The DOJ, HHS, Federal Bureau of Investigation and other agencies are armed with new auditing and data mining tools to track and trap Medicare cheaters, the letter states. “We will continue to escalate our efforts to prevent fraud and pursue it aggressively when it has occurred,” the letter adds, citing recent “record-high collections and prosecutions.”

The letter underscores the government’s full-court press against all forms of Medicare fraud, including upcoding of medical services, record cloning and the questionable billing practices where care management services and outlier facilities are involved. The letter also warns about the dangers of information that is “cut and pasted” from one section of a patient’s record to another, which can inadvertently create errors.

In its written response, also sent Monday, the American Hospital Association (AHA) acknowledged the seriousness of fraud, but also noted that documentation itself is not a silver bullet. “[M]ore accurate documentation and coding does not necessarily equate with fraud,” wrote Rich Umbdenstock, AHA’s chief executive officer.

Umbdenstock also notes that the AHA has made 11 requests since 2001 for the Centers for Medicare & Medicaid to create national guidelines on the reporting of emergency room and clinic visits, stating that the Current Procedural Terminology evaluation and management (E/M) codes currently in use were designed for physicians and are not flexible enough to handle the diverse situations hospitals encounter, especially in the emergency departments. To date, CMS has not taken action, the letter notes.

Umbdenstock also accuses CMS of “drowning hospitals with a deluge of redundant audits, unmanageable medical record requests and inappropriate payment denials.” What hospitals need, he says, is “clearer guidance from CMS, not duplicative audits that divert much needed resources from patient care.”

The Association of Academic Health Centers (AAHC) echos the need for better E/M coding guidelines in its own written response, while also expressing concern “regarding the system of incentives for and oversight of Medicare Recovery Audit Contractors (RACs). AAHC applauds the efforts of CMS’ Center for Program Integrity to develop risk-based assessment tools for the prevention of fraud, waste, and abuse, and hopes that those efforts can be expanded to the work of the RACs.”

This week’s exchange of letters is the latest in the often-prickly relationship between CMS and provider organizations.

Read the Holder/Sebelius letter as posted by KHN

Pamela Tabar

Pamela Tabar was editor-in-chief of I Advance Senior Care from 2013-2018. She has worked as a writer and editor for healthcare business media since 1998, including as News Editor of Healthcare Informatics. She has a master’s degree in journalism from Kent State University and a master’s degree in English from the University of York, England.