by Ann Triebsch

The 2013 Work Plan released October 2, 2012, by the HHS Office of the Inspector General (OIG), demonstrates that even the health care industry’s brand-new electronic health records (EHR) initiative is already under scrutiny for potentially abusive and erroneous practices by some providers.  The Work Plan lists three activities that indicate that the OIG is not planning to let any bad habits (or bad actors) get established as providers get comfortable with their new EHR systems.

Identical Documentation. In the Work Plan section on Medicare Parts A and B, the OIG reports that Medicare contractors have noted an increased frequency of medical records with identical documentation for different services.  So, in the course of examining inappropriate payments for Evaluation & Management (E/M) services and the consistency of E/M medical review determinations, the OIG will review multiple E/M services for those same providers, looking for EHR documentation practices that may be associated with potentially improper payments. 

Identical documentation may occur due to use of template-based records creation, which can lead to (overly) standardized documentation.  The use of templates has the benefit of creating standardized documentation, but the documentation must be clinically relevant and appropriate to the patient, and properly support claims to Medicare and Medicaid for services rendered.  Identical documentation also may occur as a result of the overuse or inappropriate use of the “copy and paste” function.  This practice can lead to issues with Medicare and Medicaid billing compliance, clinical appropriateness, and documentation errors. 

Providers should examine their EHR documentation practices to ensure that claims are properly supported in the record.  In particular, providers should scrutinize their “copy and paste” practices and consider severely limiting them to certain approved text or even prohibiting the use of “copy and paste” entirely.

EHR system design. As part of its review of automated information systems, the OIG plans to look at opportunities for fraud and abuse that may be present in EHR systems, and how certified EHR technology addresses those vulnerabilities.  To the extent that OIG identifies weakness or opportunities for improvement, providers should expect to see remedies incorporated into upcoming revisions of the EHR certification regulations.

Review of incentive payments. Finally, OIG will be reviewing incentive payments made to eligible Medicare and Medicaid providers for adopting EHRs, in accordance with the American Recovery and Reinvestment Act of 2009 and its provisions known as the Health Information Technology for Economic and Clinical Health Act (HITECH Act), as well as CMS’s safeguards to prevent and recoup erroneous payments. While this activity focuses primarily on CMS and its actions, the OIG review likely will become available to the EHR incentive program audits, where further action against specific providers could occur. 

So, there’s no chance to rest easy here.  Providers should implement compliance program policies that guide clinicians on documentation issues that could give rise to a claim of fraud and abuse as well as ensure that its EHR vendor is continuing to ensure that the system meets the government’s current certification standards. Providers also should ensure that they retain backup documentation supporting certification of compliance with the meaningful use criteria that lead to HITECH Act incentive payments.