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OIG report highlights continued focus on E/M payments, EHRs

APCs Insider, June 6, 2014

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The Office of Inspector General (OIG) released its semiannual report to Congress last week, highlighting areas of enforcement focus, including hospital clinic visits and electronic health records (EHRs).
OIG found that Medicare made an estimated $7.5 million in incorrect outpatient payments to hospitals for established patient E/M clinic visits in 2010 and 2011. The hospitals said the incorrect payments were due to clerical errors, staff misunderstanding of Medicare's clinic billing rules, reliance on codes selected by physicians for the visit, or billing systems that can't identify established patients.
In addition, the report noted that Medicare does not have edits in place to identify payments for patients already registered at a facility.
OIG suggested that MACs provide additional guidance to hospitals on billing clinic visits for new and established patients. Generally, patients who have been registered as an inpatient or outpatient in the same hospital, or seen a physician in the same practice or group, within three years are considered established.
CMS and its contractors have also lagged behind in updating their processes for identifying and investigating fraud in EHRs, according to OIG. It found that few contractors reviewed EHRs differently than traditional paper records. Not all contractors are able to identify copied language or overdocumentation in EHRs, either. OIG partially attributed this to limited guidance from CMS to contractors on EHRs.
OIG recommended CMS provide more guidance and also direct contractors to use providers' audit logs to distinguish EHRs from paper records. CMS should also develop guidance on the use of copy-paste in EHRs for providers, according to OIG.
For more on OIG's recent activity, review the spring 2014 report.

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