Fraud Accusations: Unintended Effect of Electronic Charts
Fraud Accusations: Unintended Effect of Electronic Charts
As most ED's have now converted to an electronic medical record (EMR), we find ourselves on the OIG's list as one of the specialties with the top increases in billings and, therefore, one of those being investigated for Medicare fraud. I find this rather odd, and had they thought it through when the edict for the EMR came down, very predictable. Most EMR's are designed so that they capture all of the necessary data to maximize billings. In fact, most mention that as one of their selling points. Many records done by hand, or even those dictated, leave out a piece of information that results in the record being down coded by the billing department. Hence, what may have been a level four is now billed as a level three. An EMR that is set up to adequately document a level of care will generate a higher bill. They also specifically ask for other points, such as pulse ox reads, that some of us would skip over as we are busy finishing a chart so we can keep up. No fraud on the part of the physician, they just documented in each little box as it came up. Nothing was left out so it qualified for the higher level. As we have become more efficient in preparing a record that can be correctly coded, our charges increase. Increases in billings and charges may represent fraud to a bureaucrat, not better documentation. An unintended consequence, perhaps, of the specialty using an EMR. So the investigation begins. Our members should all be aware of this. According to the feds, we are all liable for what is billed in our names. If they feel the charges are in excess, they will approach both you and the billing company. This shows why it is so important to be able to see what is being billed in your name. Not being able to do so may place you at an increased risk of being audited.
In December, we are scheduled to attend a hearing at the IRS/Treasury regarding being able to submit a bill for services in a timely fashion. The original proposal was to wait 240 days until one could submit a bill to a "cash paying" patient that was seen at a non-profit institution. The media jumped on this and began showing an outlier that was approaching families of patients on life support about paying their bills. We would all agree that that practice is extreme. I think we would also agree that having to wait eight months to ask for payment is also a bit extreme. I know of no business that could do that and survive. Thirty days is the practice of most businesses and is the time limit for which we have advocated. There are many groups who would suffer financial hardship if they could not even bill such a patient for eight months. No telling when/if the actual payment would occur.
Another issue coming to the forefront is that of state Medicaid insurers not paying for services rendered by the emergency physician since the condition, per discharge diagnosis, was not a true medical emergency. Thus, a middle-aged patient with a chief complaint of "chest pain" and a discharge diagnosis of chest wall pain would be denied payment. This goes on despite the prudent layperson law. Washington state fought this at the start of the year, as did TN, now VA and LA Medicaid payers have initiated the practice. I have taken this issue to the Emergency Medicine Action Fund. They suggested that it was more of a state issue, despite state Medicaid being regulated by CMS. They are writing a letter to the regulators, as is the Academy. We will also work with the affected state chapters to assist them in stopping this practice. As state treasuries become depleted and they look for ways to decrease expenditures, this looks to them to be one way to do so. They continue to provide the benefit to the constituents yet do not pay the providers. Not exactly a prudent practice, Ebenezer!
As most ED's have now converted to an electronic medical record (EMR), we find ourselves on the OIG's list as one of the specialties with the top increases in billings and, therefore, one of those being investigated for Medicare fraud. I find this rather odd, and had they thought it through when the edict for the EMR came down, very predictable. Most EMR's are designed so that they capture all of the necessary data to maximize billings. In fact, most mention that as one of their selling points. Many records done by hand, or even those dictated, leave out a piece of information that results in the record being down coded by the billing department. Hence, what may have been a level four is now billed as a level three. An EMR that is set up to adequately document a level of care will generate a higher bill. They also specifically ask for other points, such as pulse ox reads, that some of us would skip over as we are busy finishing a chart so we can keep up. No fraud on the part of the physician, they just documented in each little box as it came up. Nothing was left out so it qualified for the higher level. As we have become more efficient in preparing a record that can be correctly coded, our charges increase. Increases in billings and charges may represent fraud to a bureaucrat, not better documentation. An unintended consequence, perhaps, of the specialty using an EMR. So the investigation begins. Our members should all be aware of this. According to the feds, we are all liable for what is billed in our names. If they feel the charges are in excess, they will approach both you and the billing company. This shows why it is so important to be able to see what is being billed in your name. Not being able to do so may place you at an increased risk of being audited.
In December, we are scheduled to attend a hearing at the IRS/Treasury regarding being able to submit a bill for services in a timely fashion. The original proposal was to wait 240 days until one could submit a bill to a "cash paying" patient that was seen at a non-profit institution. The media jumped on this and began showing an outlier that was approaching families of patients on life support about paying their bills. We would all agree that that practice is extreme. I think we would also agree that having to wait eight months to ask for payment is also a bit extreme. I know of no business that could do that and survive. Thirty days is the practice of most businesses and is the time limit for which we have advocated. There are many groups who would suffer financial hardship if they could not even bill such a patient for eight months. No telling when/if the actual payment would occur.
Another issue coming to the forefront is that of state Medicaid insurers not paying for services rendered by the emergency physician since the condition, per discharge diagnosis, was not a true medical emergency. Thus, a middle-aged patient with a chief complaint of "chest pain" and a discharge diagnosis of chest wall pain would be denied payment. This goes on despite the prudent layperson law. Washington state fought this at the start of the year, as did TN, now VA and LA Medicaid payers have initiated the practice. I have taken this issue to the Emergency Medicine Action Fund. They suggested that it was more of a state issue, despite state Medicaid being regulated by CMS. They are writing a letter to the regulators, as is the Academy. We will also work with the affected state chapters to assist them in stopping this practice. As state treasuries become depleted and they look for ways to decrease expenditures, this looks to them to be one way to do so. They continue to provide the benefit to the constituents yet do not pay the providers. Not exactly a prudent practice, Ebenezer!