HEALTH INFORMATION TECHNOLOGY CAN ADDRESS HEALTHCARE FRAUD

Reports Say ‘Substantial Savings’ Possible with Automated Coding Tools and a Nationwide Network of Interoperable EHR’s

CHICAGO, October 17—The Foundation of Research and Education (FORE) of the American Health Information Management Association (AHIMA) issued two reports today detailing how health information technology can address the growing problem of healthcare fraud.

The reports are the result of a six month project conducted under contract to the Office of the National Coordinator for Health Information Technology (ONC) within the U.S. Department of Health & Human Services (HHS) that involved two main tasks: 1) a descriptive study of the issues and steps in the development and use of automated coding software that enhance healthcare anti-fraud activities; and 2) identifying best practices to enhance the capabilities of a nationwide interoperable health information technology infrastructure to assist in prevention, detection and prosecution in cases of healthcare fraud or improper claims and billing.

"These reports show that information technology can change the way we think about preventing fraud and abuse," says National Health Information Technology Coordinator, David J. Brailer, M.D., Ph.D. “Information technology can give us new tools to reduce healthcare fraud losses.”

While only a small percentage of the estimated 4 billion healthcare claims submitted each year are fraudulent, the total dollars in fraudulent or improper claims is substantial. In 2003 alone, The National Healthcare Anti-Fraud Association (NHCAA) estimates that at least 3 percent of the nation’s healthcare expenditures, or $51 billion, was lost to outright fraud. Other estimates by government and law enforcement agencies place the loss as high as 10 percent of annual expenditures, or $170 billion each year. According to the Centers for Medicare and Medicaid (CMS), fraud may take different forms, such as incorrect reporting of diagnoses or procedures to maximize payments, fraudulent diagnosis, and billing for services not rendered. In addition, patterns of inaccurate claims that may be interpreted as fraudulent can unknowingly be submitted.

An expert cross-industry committee composed of senior level executives from both the private and public sectors, including representatives of providers, payers, information technology, fraud investigative services, finance, and government developed the following set of Guiding Principles:

1. The Nationwide Health Information Network (NHIN) policies, procedures, and standards must proactively prevent, detect, and reduce healthcare fraud rather than be neutral to it.
2. EHRs and information available through the NHIN must fully comply with applicable federal and state laws and meet the requirements for reliability and admissibility of evidence.
3. A standard minimum definition of a Legal Health Record (LHR) must be adopted for electronic health records (EHRs).
4. Comprehensive Healthcare Fraud Management programs must enable rather than inhibit nationwide EHR adoption.
5. Healthcare Fraud Management is the responsibility of all healthcare stakeholders.
6. Increased consumer awareness of healthcare fraud and the role health information technology and EHRs play in its reduction can improve the effectiveness of healthcare fraud management programs.
7. EHR standards must define requirements to promote fraud management and minimize opportunities for fraud and abuse, consistent with the use of EHRs for patient care.
8. Standardized reference terminology and up to date classification systems that facilitate the automation of clinical coding are essential to the adoption of interoperable EHRs and the associated IT enabled healthcare fraud management programs.
9. Fully integrate and implement fraud management programs and advanced analytics software in interoperable EHRs and the NHIN to achieve all of the estimated potential economic benefits.
10. Data required from the NHIN for monitoring fraud and abuse must be derived from its operations and not require additional data transactions.

 Each of these Guiding Principles is accompanied by a set of recommendations for consideration by the American Health Information Community the Community ) as it begins the work of developing recommendations to HHS for achieving digital and interoperable health records within ten years.  “These principles are intended to guide policy makers and to support the needs of the vast majority of providers of services who are striving to comply honestly with  laws and requirements that affect billing and reimbursement,” says project committee co-chair Donald W. Simborg, MD, independent consultant and member, Joint Public Policy Committee of AMIA and AHIMA. “While many of the recommendations cannot currently be implemented, they identify the future technology, capability, and capacity that will be needed.”

In addition, the researchers developed an economic impact model to serve as a framework for tracking fraud and non-fraud related costs/benefits associated with developing and implementing a nationwide interoperable health information network (NHIN) with interoperable EHR’s.

“A large net reduction in health care fraud-related spending is within reach,” says project committee co-chair Arnold Milstein, MD, MPH, medical director, Pacific Business Group on Health and chief physician at Mercer Human Resource Consulting, San Francisco, CA. “But only if it is explicitly targeted in the NHIN's design and execution.”

To access the complete reports, go to http://www.ahima.org/fore/fraudrpt.asp.

AHIMA is the premier association of health information management (HIM) professionals. AHIMA's 51,000 members are dedicated to the effective management of personal health information needed to deliver quality healthcare to the public. Founded in 1928 to improve the quality of medical records, AHIMA is committed to advancing the HIM profession in an increasingly electronic and global environment through leadership in advocacy, education, certification, and lifelong learning. For information about the Association, go to www.ahima.org.

FORE provides financial and intellectual resources to sustain and recognize continuous innovation and advances in HIM for the betterment of the profession, healthcare, and the public. For more information about FORE, go to http://www.ahima.org/fore/.

The mission of ONC is to implement the President's vision for widespread adoption of interoperable electronic health records (EHRs) within 10 years. Appointed in May 2004, Dr. David Brailer, National Coordinator of Health Information Technology, serves as the principal  advisor to the Secretary of Health & Human Services and ensures HHS’ health IT policy and programs are coordinated with those of other relevant executive branch agencies. Dr. Brailer’s office develops and maintains strategic plans to guide the nationwide implementation of interoperable EHRs in both the public and private healthcare sectors, helps coordinates health information technology programs and initiatives across the federal enterprise, coordinates all outreach activities to the private industry, and serves as the catalyst for healthcare industry change. For more information about ONC, go to http://www.hhs.gov/healthit.