New fraud

September 1, 2011 -- Though retired now, my brilliant and inspiring grad school professor Dr. Donald W. Simborg continues to expound and illuminate. He writes with authority, having served as co-chair of the expert panel of a study group related to the Nationwide Health Information Network (NHIN) that looked at healthcare fraud.

He says, "Healthcare fraud is the most lucrative thing you can do if you're a crook... We're talking about a $250 billion problem."

In this month's J Am Med Inform Assoc (9/1/2011;18(5):675-7), he decries new techniques for fraud that have become enabled by modern electronic medical record (EMR) systems. These include:

  • Identity theft of provider IDs and patient IDs. This enables the fabrication of fraudulent claims.

  • Record cloning -- another way of producing fraudulent claims.

  • Copy forward -- data that is entered ahead of its actual collection, e.g. vital signs entered the day before the patient visit.

  • Single-click notes -- templated notes entered prior to the patient visit and subsequently left unaltered.

  • "Make me an author" -- an EMR feature that enables a physician to substitute their signature attribution for that of the person who actually entered a note.

  • Unaudited edits -- another "feature" that enables retroactive editing of a note without logging the amendment. Some vendors even enable the suspension of audit trail logging.

  • Evaluation and Management (E&M) code optimization -- Some EMRs suggest "upcoding" (changing the Current Procedural Terminology (CPT) service code from which billing is generated to a more expensive one) of E&M codes, and indeed with the increasing use of EMRs we have seen a rise in Medicare billings.

I applaud my professor's call for better industry oversight. EMRs can do much to improve quality, continuity, and research in healthcare. They must not also serve as tools for fraud.

Table of Contents