As use of EHRs increases, so too does the potential for fraud.

The use of electronic health records (EHRs) is expanding at a rapid pace, and so is the opportunity for fraud involving these systems. An EHR is a digital version, or database, of a patient’s paper charts. The systems allow for real-time sharing of patient-centred records and better recordkeeping. While basic EHRs were only at 9.4 percent of hospitals in 2008, they were in almost 84 percent of hospitals in 2015.

A recently unsealed whistleblower complaint in the Middle District of Florida alleges that Epic Systems’ EHR caused hospitals to double-bill Medicare and Medicaid for anaesthesia services. Epic Systems is the second-most popular EHR software on the market behind Cerner Corporation.

The case, filed by a former compliance official at a North Carolina hospital that used Epic’s EHR, alleges that a glitch in the software allowed for double-billing. On Jan. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) changed its billing rules for anaesthesiologists. Prior to 2012, anaesthesiologist time was billed in 15-minute “base units.” Starting in 2012, CMS required that anaesthesia services be billed for the actual time a physician spends on a procedure.

According to the whistleblower lawsuit, Epic’s EHR billed for both the actual time a physician spent, and for the equivalent base units, adding the minutes together in the final claims that were submitted to Medicare or Medicaid. When the whistleblower pointed this issue out to Epic, they fixed the glitch, but allegedly only for the whistleblower’s North Carolina hospital. The complaint provides only one example of double-billing at a different hospital, in Texas. In that case, a removal of a prostate was billed for 420 minutes, or seven hours, of anaesthesiologist time. However, the anaesthesia procedure summary states that the whole surgery took less than five hours.

The United States Department of Justice has declined to intervene in the whistleblower’s action, and Epic has responded publicly to the lawsuit, saying that the whistleblower has a “fundamental misunderstanding of how claims software works.”

As a customer, the United States has not provided any insight into why it declined to intervene. However, we can speculate that the double-billing problem is not as widespread as the whistleblower alleges, or that the software de-duplicated its records on the back end.

To put this case in context, it is important to note this is the second recent whistleblower case against an EHR software producer. In May, eClinicalWorks(ECW) settled a False Claims Act case for $155 million. In that case, ECW allegedly misrepresented the capabilities of its software when the EHR was being tested for CMS certification.

Healthcare providers that use CMS-certified EHR software qualify for incentive payments from CMS. Instead of developing software that met the relevant requirements, ECW allegedly designed software to pass the certification requirements without actually meeting the certification criteria. ECW also was accused of paying kickbacks to users in exchange for attestations by users that the software met the certifying criteria.

While EHR programs are now a part of day-to-day life in the healthcare field, so is the potential for fraud associated with the software. The vigilance of doctors, nurses, coders, and hospital employees will be essential in combating this new area of fraud. 

Program Note: Listen to Mary Inman on Monitor Mondays next Monday 10 a.m. ET, as she reports the latest news on hospitals accused of retaining fraudulent EHR incentive payments. 

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