At the Intersection of Health, Health Care and Policy Cite this article as: Donald W. Simborg Fraud And Electronic Health Records Health Affairs, 33, no.10 (2014):1877 doi: 10.1377/hlthaff.2014.0916
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2014 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
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Letters There is a limit of 300 words for letters to the editor. Health Affairs reserves the right to edit all letters for clarity, length, and tone. Letters can be submitted by e-mail, [email protected], or the Health Affairs website, http:// www.healthaffairs.org.
doi:
10.1377/hlthaff.2014.0916
Fraud And Electronic Health Records The title of Julia Adler-Milstein and Ashish Jha’s article in the July 2014 issue, “No Evidence Found That Hospitals Are Using New Electronic Health Records to Increase Medicare Reimbursements,” is misleading. In addition, the authors’ conclusion that “from a policy perspective, our findings suggest that a large-scale policy effort targeting EHR-driven fraudulent coding…is not likely to be useful” is unwarranted based on their study. Their focus on inpatient casemix and payments created a straw man. Over the years, hospitals have installed software products to enhance their reported diagnosis-related groups to Medicare. They have long ago maximized their case-mix indices and Medicare payments and continue to do so quite independently of their electronic health record (EHR) use. Adding an EHR would not be expected to change those parameters. What is alleged regarding EHRs and fraud, among other things, is that upcoding occurs in the evaluation and management Current Procedural Terminology code used for ambulatory
care visit billing. Hospital emergency department software is particularly suspect: There have been reports of egregious and obvious EHR-based gaming there, as well as in the more general ambulatory EHRs used by some hospitals. The authors have misinterpreted or chosen to ignore these aspects of the New York Times analysis1 and other articles they reference and other studies that they don’t cite, such as that done by the Center for Public Integrity.2 It is quite possible that some hospitals are using EHRs to fraudulently increase Medicare reimbursements. But we won’t know the extent until someone, unlike these investigators, looks in the right places. Donald W. Simborg MILL VALLEY , CALIFORNIA NOTES 1 Abelson R, Creswell J, Palmer G. Medicare bills rise as records turn electronic. New York Times. 2012 Sep 21. 2 Schulte F. Judgment calls on billing make “upcoding” prosecutions rare [Internet]. Washington (DC): Center for Public Integrity; 2012 Sep 15 [cited 2014 Jul 9]. Available from: http:// www.publicintegrity.org/2012/09/15/10835/ judgment-calls-billing-make-upcodingprosecutions-rare
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The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/33/10/1877.1.full.html
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php E-mail Alerts : http://content.healthaffairs.org/subscriptions/etoc.dtl To Subscribe: http://content.healthaffairs.org/subscriptions/online.shtml
Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2014 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
Not for commercial use or unauthorized distribution Downloaded from content.healthaffairs.org by Health Affairs on March 22, 2015 at UCSF Library & CKM RECS Mgmt
Letters There is a limit of 300 words for letters to the editor. Health Affairs reserves the right to edit all letters for clarity, length, and tone. Letters can be submitted by e-mail, [email protected], or the Health Affairs website, http:// www.healthaffairs.org.
doi:
10.1377/hlthaff.2014.0916
Fraud And Electronic Health Records The title of Julia Adler-Milstein and Ashish Jha’s article in the July 2014 issue, “No Evidence Found That Hospitals Are Using New Electronic Health Records to Increase Medicare Reimbursements,” is misleading. In addition, the authors’ conclusion that “from a policy perspective, our findings suggest that a large-scale policy effort targeting EHR-driven fraudulent coding…is not likely to be useful” is unwarranted based on their study. Their focus on inpatient casemix and payments created a straw man. Over the years, hospitals have installed software products to enhance their reported diagnosis-related groups to Medicare. They have long ago maximized their case-mix indices and Medicare payments and continue to do so quite independently of their electronic health record (EHR) use. Adding an EHR would not be expected to change those parameters. What is alleged regarding EHRs and fraud, among other things, is that upcoding occurs in the evaluation and management Current Procedural Terminology code used for ambulatory
care visit billing. Hospital emergency department software is particularly suspect: There have been reports of egregious and obvious EHR-based gaming there, as well as in the more general ambulatory EHRs used by some hospitals. The authors have misinterpreted or chosen to ignore these aspects of the New York Times analysis1 and other articles they reference and other studies that they don’t cite, such as that done by the Center for Public Integrity.2 It is quite possible that some hospitals are using EHRs to fraudulently increase Medicare reimbursements. But we won’t know the extent until someone, unlike these investigators, looks in the right places. Donald W. Simborg MILL VALLEY , CALIFORNIA NOTES 1 Abelson R, Creswell J, Palmer G. Medicare bills rise as records turn electronic. New York Times. 2012 Sep 21. 2 Schulte F. Judgment calls on billing make “upcoding” prosecutions rare [Internet]. Washington (DC): Center for Public Integrity; 2012 Sep 15 [cited 2014 Jul 9]. Available from: http:// www.publicintegrity.org/2012/09/15/10835/ judgment-calls-billing-make-upcodingprosecutions-rare
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