Sebelius, Holder Make Strong Statement Against EHR-Related Fraud

Kathleen Sebelius, Secretary of the U.S. Department of Health & Human Services (HHS) and Eric Holder, Attorney General for the U.S. Department of Justice, sent a strongly worded letter to various provider-based organizations, touting its resolve to prevent EHR-related healthcare fraud. In the letter, Sebelius and Holder note that there has been “troubling indications” that some providers are using EHRs to “game the system,” and obtain payments, which they are not entitled.

“False documentation of care is not just bad patient care, it’s illegal,” they wrote in the letter. “These indications include potential ‘cloning’ of medical records in order to inflate what providers get paid. There are also reports that some hospitals may be using electronic health records to facilitating ‘upcoding’ of intensity of care or severity of patients’ condition as a means to profit with no commensurate improvement in the quality of care.”

In the letter, Sebelius says the Centers for Medicare and Medicaid Services (CMS) is specifically reviewing billing through audits to identify and prevent improper billing. It also says its initiating more extensive medical reviews to ensure coding evaluation and management services are accurate.

The letter was sent out this week to the American Hospital Association (AHA), the Federation of American Hospitals, the Association of Academic Health Centers, the Association of American Medical Colleges, and the National Association of Public Hospitals and Health Systems. In a response, Rich Umbdenstock, President and CEO of the AHA, threw it back at the government, saying the organization has requested guidelines for evaluation and management (E/M) codes, and have not received them.

“What’s needed is clearer guidance from CMS, not duplicative audits that divert much needed resources from patient care. In recent years, CMS has drastically increased the number of program integrity auditors that review hospital payments to identify improper payments. No one questions the need for auditors to identify billing mistakes; but the flood of new auditing programs, such as Recovery Audit Contractors, MACs and others, is drowning hospitals with a deluge of redundant audits, unmanageable medical record requests and inappropriate payment denials,” Umbdenstock said in the letter.