A new report issued by the Agency for Healthcare Research and Quality warns against the danger of an increase in healthcare fraud as more providers upgrade to new electronic health records systems. According to this report, EHR software should make it easier to detect fraudulent activity, yet very little is being done to combat these issues. The AHRQ concludes the section of their report on fraud with a list of recommendations meant to reduce the number of false claims filed with EHR software.
Cost of fraud
Healthcare fraud is brutally expensive. Citing the FBI's reports on healthcare fraud, the AHRQ reports the FBI estimates that fraudulent insurance claims account for $80 billion total annual loss. In addition to immediate losses suffered as a result of false claims, the FBI also spends over half a billion dollars yearly investigating healthcare fraud. EHR software should make these issues more transparent, allowing investigators to quickly and efficiently filter through huge swathes of data. However, while EHR makes some forms of investigation easier, they also give rise to new forms of fraud.
According to the AHRQ study, there are two emergent practices that account for the majority of EHR counterfeit claims. The first is to "clone" patient records. By copying and pasting billing information from a patient's files who actually received the treatment to another's, criminals can easily dupe the system into paying out extra money for procedures that never occurred. A similar method of fraud is referred to as "up-coding," whereby additional or more expensive procedures are tacked onto a patient's claim in order to extract more money.
The U.S. Department of Health and Human Services acknowledges the risks EHR software presents, and they have taken precautions to implement advanced technology and analytics to predict and detect potential healthcare fraud schemes. Despite these claims, the AHRQ report states that the HSS has actually terminated 400 of its fraud detection staff, including those individuals working on bringing the aforementioned "sophisticated technology" to term.
The AHRQ concludes their report by suggesting that the HSS should use data-mining and predictive analytics to identify trends in fraud. It continues that a data enclave should be established to support the development of fraud-detection software. Although the AHRQ places the burden of developing these safeguards against fraud on the shoulders of the government, EHR software developers can also contribute to the cause by building additional fraud-detection measures into their products.
It is important to note that many of the instances of fraud are not the results of flaws in the electronic health record software. The individuals who have been misusing EHRs have not been exploiting bugs. They are not hackers or cyber-criminals. They are, unfortunately, healthcare providers, who do not seem to understand the broad reaching consequences of their actions. People defrauded insurance agencies like Medicaid and Medicare with paper records before electronic health records were even conceived of. Still, the breakneck speed with which EHR has been injected into the healthcare world has led to new forms of fraud. Hopefully, the delay of the implementation of Meaningful Use stage 2 requirements, which was announced in early June by the CMS, will allow fraud-prevention practices to catch up.