Physicians might not realise it, but how they and their staffs use an electronic medical record system could open themselves up to accusations of fraud or misrepresentation.
The problem isn’t that physicians are intentionally trying to double-bill or make it appear that they are trying to alter patient records. It’s that systems are vulnerable to being used in a way that makes it seem as if they are. Or the systems might not have certain features that would help protect the practice from these allegations.
A 2007 document from the American Health Information Management Assn. warns physicians that they should not expect unintentional deception or misrepresentation to be viewed more favorably by payers, evaluators or litigators than actual fraud, which, by definition, requires intent. Some of the issues at play are authorship integrity, auditing integrity and documentation integrity, according to the AHIMA report.
Reed Gelzer, MD, COO of Advocates for Documentation Integrity and Compliance, an education, training and consultancy firm focused on EMR quality and information integrity standards, said that to protect themselves, physicians need to know how their systems work and how they can address any pitfalls.