Copy/paste errors continue to plague EHRs as a serious issue in clinical documentation.
Felicia Heimer, a senior attorney with the HHS OIG, spoke with the Journal of AHIMA and outlined key fraud and abuse issues in clinical documentation. She also offered some tips on how to avoid these errors and remain in compliance with the law.
1. Copy/paste. "When providers engage in cloning (copying portions of an existing record and adding it to another), inaccurate information may be entered into the patient's record, which could result in inappropriate charges being billed to patients and third-party payers," Ms. Heimer said.
2. Billing for unnecessary or un-rendered services. Ms. Heimer said such practices make up a significant portion of healthcare fraud cases every year. The core issue here, she said, is the sufficiency and accuracy of medical records and claims-related documentation.
When it comes to avoiding these documentation mistakes, Ms. Heimer said training is key. Training, she said, is a focus are for the OIG, as it has issued a compliance program guideline and educational initiatives to underscore the importance of proper, adequate clinical documentation.
Additionally, the government's attention to fraud and abuse issues is likely to rise, according to Ms.Heimer. "The government will continue to increase and refine its enforcement efforts," she said. "The OIG has recently announced the formation of a litigation team that will solely focus on levying civil monetary penalties and excluding individuals. The healthcare provider community should expect to see an increase in the number of enforcement cases, particularly kickback cases that are initiated — not only against the payer of the kickback, but also the recipient of the kickback, which tends to be a physician."
To prevent a run-in with the law, Ms. Heimer said simply doing the right thing to remain compliant is the best course of action, not only to prevent errors but also if/when a violation occurs.
"Do the right thing to prevent violations from happening in the first place, and do the right thing when a violation has come to light," she said. "The costs associated with responding to a government's investigation or defending against a lawsuit, and the tolls that those activities take on employees and on an organization’s reputation — are great. I am fairly sure that, in most cases, doing the right thing saves money in the long run."
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