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    Federal government to crack down on Medicare upcoding

    Some providers use EHRs to 'game the system,' report alleges


    Washington—With Medicare in the crosshairs of political debate and the need to cut spending paramount before year's end, Congress now has additional data that shows that many health care providers are gaming the coding system in order to increase payments.

    The latest report from the Center for Public Integrity follows a May report to Congress by the Government Accountability Office that found that evaluation and management services billings had increased by 48% between 2001 and 2010 and recommended that the Centers for Medicare & Medicaid Services take action.

    The new report found that during that 10-year period, physicians increasingly billed Medicare for higher paying codes than in the past to the tune of $11 billion, while cutting back on lower paying codes.

    The center's probe uncovered a broad range of billing errors and abuses, from confusion over how to select proper codes to outright overcharges. The findings also showed that Medicare billing problems are becoming more serious as doctors and hospitals switch to electronic health records.

    As a result of the study, U.S. Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder notified five hospital trade organizations of their intention to increase investigative oversight and that criminal prosecutions are possible.

    In their letter to the hospital organizations, Sebelius and Holder said there are indications that some providers are using technology "to game the system" to obtain payments to which they are not entitled.

    "There are also reports that some hospitals may be using electronic health records to facilitate 'upcoding' of the intensity of care or severity of patients' condition as a means to profit, with no commensurate improvements in the quality of care," their letter said.

    The two officials said CMS is reviewing billing through audits to identify and prevent improper billing and is "initiating more extensive medical reviews to ensure that providers are coding… accurately."

    "Law enforcement will take appropriate steps to pursue health care providers who misuse electronic health records to bill for services never provided," they said.

    While Medicare and its financing was a major issue during the presidential campaign, lawmakers now face the task of preventing the massive across-the-board cuts scheduled to be imposed at year's end by the budget agreement earlier this year. Medicare will be under intense scrutiny, and reports such as this will not be helpful to physicians who seek to avoid further reimbursement reductions in addition to the ones threatened as a result of the ongoing Medicare fee schedule problems.


    Bob Gatty
    Bob Gatty, a former congressional aide, covers news from Washington for Urology Times.


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