Electronic Medical Record Issues

A recent report released  by the Office of the Inspector General for the Health and Human Services Department both details and warns about the current issues brought on by the rollout of Electronic Medical Records (EMR).  (The conversion of patient medical records from traditional “paper charts” to electronic charts is being fueled by more than $22 billion in incentives offered by the federal government.) The major issues that have been reported once these systems have been implemented are inflation of costs and over-billing.

Physician practices and hospitals who have not implemented proper compliance programs, safeguards and respective training for utilization of  these EMRs are at risk of improper usage, specifically usage of the “copy-and-paste function.”  This function, also known as cloning, is an available function in many of the largest EMRs.  Basically, by copying a pasting, a provider can reduce the time spent on inputting patient data as it allows patient information to be quickly copied from one document to another.  The risk of this is that this method can also allow, even if it was not the intent, improperly indication of higher-reimbursing patient exams or treatments than actually occurred.

The result of lack of compliance programs, safeguards and training greatly increases the practice/hospital’s risk of over-billing and thus brings tremendous exposure to Medicare audits and, even worse, suspicion of fraudulent activities.  The typical amount of refund asked by Medicare audits for physician practices can range, depending on practice size, from half a million to a million dollars.  For hospitals, these fines can be in the tens of millions of dollars.

A report and analysis released last month by the inspector general’s office showed that 75% of the hospitals surveyed had no formal compliance program, or safeguards/policies regarding the utilization of copy-and-paste functions.

Aside from hospital and physician practice responsibilities to implement compliance plans and safeguards, Medicare officials have also stated that the prevention of fraud via EMRs is a top priority on their end as well.  Specifically, Medicare officials have stated they are working to create standards on their end for proper validation of EMR systems and better instructions for their contractors so users can quickly and properly adopt their new systems.

While these standards/instructions are being developed by Medicare, providers can reduce exposure to audit by implementing compliance programs and safeguards and also perform routine coding and documentation audits.