The Perils of Copy and Paste

Electronic health records (EHR) systems can be complex and costly, challenging to learn and difficult to navigate. And yet, one of the simplest aspects of using EHR can get you in trouble: the ability to electronically copy and paste patient data from old records into new ones.

Whether you call it copy and paste, cloning or carrying forward, the practice is convenient, but risky. According to the American Health Information Management Association (AHIMA), the practice can lead not only to patient care that is diminished or even dangerous, but also to reimbursement issues, as auditors and payers have begun to question records that look suspiciously alike.

AHIMA cites several examples of the possible consequences:

  • Overpayments — and recoupment — of charges for services that were performed once but documented repeatedly.
  • Misrepresentation of who performed a service, which can affect the amount billed.
  • Damage to credibility leading to denial of payment and even charges of fraud.

In a recently released study of 2,068 electronic patient progress reports, researchers found that the vast majority of notes by residents and attending physicians contained 20 percent or more material that was copied and pasted from earlier records. The research team from Case Western Reserve University School of Medicine in Cleveland used plagiarism-detection software to analyze notes made for 135 patients over a five-month period in the intensive care unit of a Cleveland hospital.

Recognizing the potential for overpayment, some payers have begun to establish formal policies prohibiting the use of copy and paste functions. In a 2012 letter to industry medical groups, U.S. Department of Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder emphasized that patient care information must be individually verified and not copied and pasted from previous records. And a January 2014 report by the Office of Inspector General urged the Centers for Medicare and Medicaid Services (CMS) to strengthen its ability to identify fraud resulting from copy and paste practices.

Medical professionals should avoid the use of any practices that could create the appearance of fraud. Contact a health care attorney for counseling on steps you can take to ensure compliance and avoid legal problems.

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Posted in: Compliance, Reimbursement