Dr. Julie Taitsman, Chief Medical Officer for OIG, gave a presentation recently as a part of OIG’s award-winning HealthCare Fraud Prevention and Enforcement Action Team (HEAT) entitled, The Importance of Documentation. The information in Dr. Taitsman’s presentation can help you to better understand the issues surrounding proper medical records documentation in patient medical records and in Medicare claims and bills. This blog post is the second of a two-part series on the topic. You can read The Importance of Documentation for Medicare and Medicaid Claims, Part I now.

Accurate Records Protect Providers

If your medical records are selected for review, clear records will help you to withstand scrutiny. Stiff fines are paid for upcoding and providers can be sentenced to probation and/or house arrest if convicted. An endocrinologist recently paid almost $500,000 in fines for upcoding routine blood draws to higher-paying, critical-care blood draws. A dermatologist paid almost $3,000,000 in fines for falsifying diagnosis codes for a condition covered by Medicare when the patient’s actual condition was not covered. This same doctor was sentenced to two years of probation and six months’ house arrest.

Here are a few good tips to keep in mind when the OIG reviews the legitimacy of your claims and services:

• If it wasn’t documented, it didn’t happen.
• Clear information showing your rationale for performing a diagnostic test helps demonstrate why a medical test was necessary and will help you meet the medical necessity requirement.
• Clear recording of test outcomes helps substantiate that the test was completed and can also prove the need for subsequent care that may be billed later.

In one of the OIG’s ongoing studies, they have reviewed a number of records documenting medical imaging and found most of them to be complete and legible, with detailed histories, test results and explanation of treatment plans. Those records fully support the services claimed and those providers don’t have to worry about Medicare knocking on their doors to request that money be repaid.

However, the OIG has also reviewed imaging records that contain little more than the patients’ names, a chief complaint and some vital signs. In one example, no information was recorded about the service performed that Medicare was billed for, other than the letters CXR, indicating that the patient got a chest x-ray. Nothing was recorded to state that anyone read the chest x-ray or used it in any subsequent treatment. In a post-payment review of claims not supported by documentation of the medical record, CMS may, at the very least, require that the provider repay Medicare and Medicaid for the money that was received.

Enforcing Documentation

Most claims are processed automatically, but CMS does not have to automatically pay claims. If necessary, claims can be subject to:

• Post-payment/retrospective review – CMS will review suspected records already billed and may require that a provider repay Medicare for services not covered.
• Prepayment review – Suspicious providers can be placed on prepayment review and payment of claims will be subject to approval by the OIG.

In the future, there will continue to be an increase in the enforcement of documentation requirements and fraud enforcement:

• The Administration is attempting to cut the improper payment rate for Medicare fee-for-service in half by 2012.
• The OIG has recommended that CMS and contractors focus on error-prone providers.
• CMS is increasingly tasking contractors to review medical records to prevent improper payments.

Pitfalls when Adopting Electronic Medical Records

Currently, many healthcare providers are adopting electronic medical health records (EMR) and this can be a great thing. They can be great for providers, increasing practice efficiency, and for patients, improving patient care. However, as providers adopt these new technologies, users should understand that there are vulnerabilities:

• Cloning – This is the cutting and pasting of information across multiple patient records or for the same patient from visit to visit. This practice is too easy with many EMR systems and must be discouraged.
• Over-documentation – These are default EMR settings that automatically fill-in full history, full exam and full review of systems info for all patients and/or for every patient visit. These systems require the provider to manually uncheck a box to delete the services not provided, often resulting in overbilling.

Keep in mind that it’s just as dishonest to allow a computer to record provided services inaccurately is as it is for a human to do it deliberately.

EMR Systems’ Security Issues

EMRs allow multiple users to access records simultaneously in different locations. However, security is as important with an EMR as it is with manual record keeping. OIG auditors may test providers by attempting to access providers’ networks from laptops in the parking lot. Providers are responsible to provide for their systems’ security.

• Remote access of patient information– Some systems allow staff to access medical information from their homes or other remote sites, and some utilize PDAs, such as smartphones or iPads. Providers must provide security for data if these features are implemented.
• Good integrity functions and change documentation– Date, time and author stamps for all data entry and changes should be a part of the system and users should not be allowed to disable these features.
• A means to make legitimate changes should be provided for.
• All changes must be signed and dated so that changes made to an original record by another author do not reflect inaccurately on the original author.
• Backdating and postdating should not be enabled if allowed by your system.
• Use of systems or features that allow patient notes to be left open for long periods of time (and backdated to the time the note was opened) should be discouraged.

Cover-ups of lack of documentation always make matters worse.

This concludes the two-part blog series entitled The Importance of Documentation. Watch Dr. Taitsman’s complete video presentation now. You can also read The Importance of Documentation for Medicare and Medicaid Claims, Part I now.