Study: 'No evidence' that EHR adoption leads to upcoding

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Hospitals do not use their electronic health records to upcode in order to obtain higher reimbursement from Medicare, according to a new study in Health Affairs.

The researchers, from the University of Michigan School of Public Health and School of Information and Harvard School of Public Health, studied 393 hospitals that adopted new EHRs from 2008-2012 and compared them to 782 control hospitals that had not. They used data from four sources to examine if the hospitals using EHRs had greater subsequent increases in patient acuity and payment from Medicare, which would likely show if they had increased coding for comorbidities and higher resulting reimbursement.

To that end, the study authors found "no evidence" of upcoding by the EHR-using hospitals. Billing to Medicare increased, but at a comparable rate to the control group. There was no significant relationship between EHRs and patient acuity and "indistinguishable" changes in payments. This was true even for hospitals that could have been more focused on using EHRs to increase billing, such as for-profit hospitals, hospitals in the most competitive markets and those with the highest percentage of Medicare patients.

The study suggested that most hospitals that had adopted EHRs had already optimized coding before adoption and that the discrepancy between their results finding no fraud and those found by the New York Times, which reported fraud in 2012, was because the latter did not use a control group for comparison.

"We failed to find evidence that EHR adopters had greater increases in Medicare patient acuity or payments compared to matched nonadopters," the authors said. "A policy intervention to reduce fraud is therefore not likely to be a good use of resources. Instead, policy makers should focus on ensuring that hospitals use EHRs in ways that are likely to reduce healthcare spending and improve the quality of care."

There has been concern that providers would take advantage of the functionalities in EHRs to upcode and otherwise engage in improper billing. The Office of Inspector General has made this concern a priority in its strategic and work plans, and has chastised the Centers for Medicare & Medicaid Services for providing its contractors with only limited guidance on EHR fraud. However, providers have steadfastly denied that EHR adoption in and of itself has caused a systemic increase in billing fraud and asserted that steps can be taken, such as audit logs and training, to forestall inappropriate use.

To learn more:
- read the abstract

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