The federal government is rewarding doctors and hospitals for moving to electronic health records — and will soon punish them if they don't — even though these records currently make it easier for health care providers to defraud government-paid health programs, fraud experts say.
The Department of Health and Human Services' inspector general charged in December that the basic auditing safeguards that also help to prevent fraud for electronic health records (EHRs) weren't in place in many hospitals, or they were being used, but vulnerable to corruption.
Yet the Centers for Medicare and Medicaid Services still doesn't require health care providers to keep their audit systems on. Reed Gelzer, a former primary care doctor who is now an EHR consultant to the federal government and private groups, says that means the health records that are maintained electronically can be easily falsified, altered or otherwise misrepresented.
"There have been billions spent on these systems and incentives paid to providers, but there is no private or government agency that provides oversight," said Dan Bowerman, a Philadelphia chiropractor who has assisted in many state and federal fraud investigations.
Preventing EHR fraud is a "top priority" for CMS, spokesman Aaron Albright said in an e-mail response.
"We are working to create strong standards for validating electronic health records to ensure that we allow beneficiaries to receive the care they need and at the same time protect taxpayers from fraud, waste and abuse," he said.
A 2009 federal law requires that certified EHRs have to be used in a "meaningful manner." This includes e-prescribing, sharing health information and allowing providers to submit clinical quality measures, such as patient care outcomes.
Electronic records can be enormously beneficial in medicine because they improve patient care and cut costs - key goals of the Affordable Care Act - by allowing doctors and pharmacists to coordinate treatment. That reduces medical errors and avoids duplication of procedures. HHS has spent more than $22.5 billion in financial incentives for doctors and hospitals to use EHRs, and those that don't will soon have their Medicare payments reduced.
The problems occur when the records aren't audited for reliability or checked for cloned records, said Bowerman, a former medical director at a major insurer. Questionable electronic documentation systems allow providers to add notes to existing records or create new records where none existed before. Some health care providers who are the subject of insurance company audits or criminal investigations have created such records, Bowerman said.
The push for EHRs comes as funding for fraud prevention has been on a downward trend, federal data show, though some funding is set to increase in 2015. Even though the Health Care Fraud and Abuse Control program and Medicare Integrity Program recover more than $8 for every $1 spent, the two programs only make up about 0.22% of total federal health care expenditures, Gelzer estimates using federal and congressional data.
CMS is working on new standards and ways to identify when records are copied and used inappropriately in future notes, wrongly modified or altered by date or author. The agency said it is also trying to identify best practices for detecting fraud and abuse associated with EHRs with the help of contractors.
Gelzer said the best way to do that will be to spur better accuracy and reliability with more funding for regulation and enforcement.
"Investigators I've spoken with say that the only constraint on more recoveries is more resources," Gelzer said.