Reports indicate health IT applications could reduce fraud

The Health and Human Services Department believes that the development and use of automated coding software and the establishment of a nationwide network of interoperable electronic health records (EHRs) would reduce health care fraud.

That conclusion is the product of two reports conducted by the American Health Information Management Association's research arm, the Foundation of Research and Education. The Office of the National Coordinator for Health Information Technology in HHS funded the research, which was released earlier this week.

Standardized reference terminology and up-to-date classification systems that allow for the automation of clinical coding are essential to the adoption of interoperable EHRs and associated IT-enabled health care fraud management programs, the reports said.

Fraud management programs and advanced analytics software should be developed and integrated in EHRs that are interoperable, and in the national health information network when it is designed, to achieve all of the potential economic benefits.

"These reports show that information technology can change the way we think about preventing fraud and abuse," said David Brailer, the national coordinator for health IT, in a statement.

While only a small percentage of the estimated 4 billion health-care claims submitted each year are fraudulent, the total dollars in improper claims is substantial. In 2003, the National Healthcare Anti-Fraud Association estimates that at least 3 percent of the nation's health care expenditures'or $51 billion'was lost to outright fraud.

Fraud may take different forms, such as incorrect reporting of diagnoses or procedures to maximize payments, fraudulent diagnosis and billing for services not rendered, said the Centers for Medicare and Medicaid Services, an agency of HHS. In addition, some inaccurate claims may be unknowingly submitted.

The research organization identified best practices for preventing fraud in health IT, including:
  • Policies, procedures and standards must proactively prevent, detect and reduce health care fraud rather than be neutral to it

  • A standard minimum definition of a legal electronic health record must be adopted

  • Comprehensive health care fraud management programs must enable rather than inhibit nationwide electronic health record adoption

  • Electronic health record standards must define requirements to promote fraud management and minimize opportunities for fraud and abuse and

  • Data required from the national health information network for monitoring fraud and abuse must be derived from its operations and not require additional data transactions.

About the Author

Mary Mosquera is a reporter for Federal Computer Week.

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