AHA Faults HHS For Lack Of E/M Guidelines As DOJ Warns Hospitals Not To Use EHR To Game System

by InsideHealthPolicy.com

The American Hospital Association told Obama administration officials Monday that it agrees fraudulent billing practices -- such as inappropriately “upcoding” the intensity of care -- should not be accepted but said some of the onus falls on HHS for failing to develop national guidelines for reporting Evaluation and Management (E/M) codes despite “numerous requests.” AHA's letter came after HHS Secretary Kathleen Sebelius and Attorney General Eric Holder warned hospital groups that the administration “will not tolerate” health care fraud and specifically pointed out that CMS has the authority to address inappropriate coding intensity adjustments through its payment rules if warranted.

The administration's strongly worded letter was sent to AHA, Federation of American Hospitals, Association of Academic Health Centers, Association of American Medical Colleges, and National Association of Public Hospitals and Health Systems. The letter was spurred by a recent reports, including a front page New York Times story, suggesting that increased usage of electronic health records, long seen as a way to create more efficiency in the health sector, are instead being used to “game” the system.

“Used appropriately, electronic health records have the potential to save money and save lives,” Sebelius and Holder wrote. But, “there are troubling indications that some providers are using this technology to game the system,” they add.

The letter says that CMS “is initiating more extensive medical reviews to ensure that providers are coding evaluation and management (E/M) services accurately.” This will include comparative billing reports that can identify “outlier” facilities.

Additionally, the letter warns that CMS has -- and will consider using -- authority to address inappropriate coding through its payment rules.

Sebelius and Holder also told the hospital groups that HHS, the Department of Justice, the FBI and other law enforcement agencies are monitoring trends and taking action if they discover providers using EHRs to bill for services never provided and other fraudulent activity. They note the health law provided new tools to combat fraud, including provisions allowing CMS to stop payments for suspicious billing and mine data, which have already contributed to “record-high” collections and prosecutions.

In its response, AHA stresses that hospitals share the administration's goals of creating a high-quality, more-affordable health system and “work hard to ensure billing is correct the first time.” But AHA suggests that HHS would be more helpful by offering greater clarity, not more “duplicative audits” that divert resources from patient care.

“No one questions the need for auditors to identify billing mistakes, but the flood of new auditing programs, such as Recovery Audit Contractors, MACs and others, is drowning hospitals with a deluge of of redundant audits, unmanageable record requests, and inappropriate payment denials,” AHA writes, pointing out that a recent survey showed that hospitals are appealing 40 percent of denials and have a 75 percent success rate. The programs need to be streamlined so that duplicative audits are eliminated, AHA says.

AHA also stresses that more accurate documentation and coding “does not necessarily equate with fraud,” and points to the need for more guidance. Hospitals have made 11 requests for CMS to develop national guidelines for E/M codes since 2001. The letter says that AHA and the American Health Information Management Association (AHIMA) in 2003 recommended that CMS move from the American Medical Association's CPT coding system, and implement guidelines developed by an independent panel of experts.

CMS said that it would consider such recommendations in its 2004 and 2005 outpatient payment rules, AHA says. “However, to date, the CMS has not established national hospital E/M guidelines,” AHA says. The FY 2013 OPPS rule proposed that hospitals should continue to report visits according to their own guidelines to determine the different levels of clinic and emergency department visits, AHA points out.

AHA says that it “stands ready to work with CMS in the development and vetting” of the national guidelines which should then be proposed to AMA's CPT board.

FAH, AAMC and AAHC did not respond by press time. The NAPH said in a response that its hospitals “adhere to high ethical standards” and reject practices that could result in fraudulent claims. “We stand ready to help regulators understand fully the many aspects of electronic health record use in the hospital setting as they consider actions to ensure proper billing practices,” NAPH said. -- Amy Lotven (alotven@iwpews.com) and Michelle Stein (mstein@iwpnews.com)


Written by:


InsideHealthPolicy.com on:

Readers' Choice 2017
Reporters on Deadline

"My best business intelligence, in one easy email…"

Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:
Sign up using*

Already signed up? Log in here

*By using the service, you signify your acceptance of JD Supra's Privacy Policy.
Custom Email Digest
Privacy Policy (Updated: October 8, 2015):

JD Supra provides users with access to its legal industry publishing services (the "Service") through its website (the "Website") as well as through other sources. Our policies with regard to data collection and use of personal information of users of the Service, regardless of the manner in which users access the Service, and visitors to the Website are set forth in this statement ("Policy"). By using the Service, you signify your acceptance of this Policy.

Information Collection and Use by JD Supra

JD Supra collects users' names, companies, titles, e-mail address and industry. JD Supra also tracks the pages that users visit, logs IP addresses and aggregates non-personally identifiable user data and browser type. This data is gathered using cookies and other technologies.

The information and data collected is used to authenticate users and to send notifications relating to the Service, including email alerts to which users have subscribed; to manage the Service and Website, to improve the Service and to customize the user's experience. This information is also provided to the authors of the content to give them insight into their readership and help them to improve their content, so that it is most useful for our users.

JD Supra does not sell, rent or otherwise provide your details to third parties, other than to the authors of the content on JD Supra.

If you prefer not to enable cookies, you may change your browser settings to disable cookies; however, please note that rejecting cookies while visiting the Website may result in certain parts of the Website not operating correctly or as efficiently as if cookies were allowed.

Email Choice/Opt-out

Users who opt in to receive emails may choose to no longer receive e-mail updates and newsletters by selecting the "opt-out of future email" option in the email they receive from JD Supra or in their JD Supra account management screen.


JD Supra takes reasonable precautions to insure that user information is kept private. We restrict access to user information to those individuals who reasonably need access to perform their job functions, such as our third party email service, customer service personnel and technical staff. However, please note that no method of transmitting or storing data is completely secure and we cannot guarantee the security of user information. Unauthorized entry or use, hardware or software failure, and other factors may compromise the security of user information at any time.

If you have reason to believe that your interaction with us is no longer secure, you must immediately notify us of the problem by contacting us at info@jdsupra.com. In the unlikely event that we believe that the security of your user information in our possession or control may have been compromised, we may seek to notify you of that development and, if so, will endeavor to do so as promptly as practicable under the circumstances.

Sharing and Disclosure of Information JD Supra Collects

Except as otherwise described in this privacy statement, JD Supra will not disclose personal information to any third party unless we believe that disclosure is necessary to: (1) comply with applicable laws; (2) respond to governmental inquiries or requests; (3) comply with valid legal process; (4) protect the rights, privacy, safety or property of JD Supra, users of the Service, Website visitors or the public; (5) permit us to pursue available remedies or limit the damages that we may sustain; and (6) enforce our Terms & Conditions of Use.

In the event there is a change in the corporate structure of JD Supra such as, but not limited to, merger, consolidation, sale, liquidation or transfer of substantial assets, JD Supra may, in its sole discretion, transfer, sell or assign information collected on and through the Service to one or more affiliated or unaffiliated third parties.

Links to Other Websites

This Website and the Service may contain links to other websites. The operator of such other websites may collect information about you, including through cookies or other technologies. If you are using the Service through the Website and link to another site, you will leave the Website and this Policy will not apply to your use of and activity on those other sites. We encourage you to read the legal notices posted on those sites, including their privacy policies. We shall have no responsibility or liability for your visitation to, and the data collection and use practices of, such other sites. This Policy applies solely to the information collected in connection with your use of this Website and does not apply to any practices conducted offline or in connection with any other websites.

Changes in Our Privacy Policy

We reserve the right to change this Policy at any time. Please refer to the date at the top of this page to determine when this Policy was last revised. Any changes to our privacy policy will become effective upon posting of the revised policy on the Website. By continuing to use the Service or Website following such changes, you will be deemed to have agreed to such changes. If you do not agree with the terms of this Policy, as it may be amended from time to time, in whole or part, please do not continue using the Service or the Website.

Contacting JD Supra

If you have any questions about this privacy statement, the practices of this site, your dealings with this Web site, or if you would like to change any of the information you have provided to us, please contact us at: info@jdsupra.com.

- hide
*With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name. Or, sign up using your email address.