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Office of The National Coordinator for Health Information Technology's Anti-Fraud Activities
2007 Activities
In late 2006, the Office of the National Coordinator for Health Information Technology (ONC) contracted with RTI International for an anti-fraud project involving three tasks: (1) development of recommendations for electronic health record (EHR) functional requirements that would enhance data by reducing the incidence of improper payment and assist in fraud management, (2) validate the recommendations through public comment, and (3) work with appropriate health It organizations to encourage adoption of the recommendations.
Recommended Requirements for Enhancing Data Quality in Electronic Health Records
The rising cost of health care has become a major issue in the United States. In 2005, the United States spent $1.98 trillion, or 16% of its gross domestic product (GDP), on health care. By 2016, health care expenditures are projected to surpass $4.1 trillion, or 19.6% of GDP. In 2006, the National Coalition on Health Care (NCHC) noted that “inappropriate care, waste and fraud were major contributors to the cost of medical care and health insurance."
Thus, widespread use of EHR systems has the potential to improve the quality of care, increase patient safety, reduce medical errors, and control health care costs.
The primary purpose of this project is to identify EHR requirements that can help enhance data protections, such as increased data validity, accuracy, and integrity including appropriate fraud management that would prevent fraud from occurring, as well as detect fraud both prospectively and retrospectively. A key component of creating these recommended requirements is to overlap whenever possible with those requirements currently in use for EHR certification. For example, authentication is required for privacy and confidentiality, but it is just as useful for preventing and detecting fraud. All of the requirements identified in this report were framed as recommendations to the industry.
2005 Activities
In April 2005, ONC contracted with the Foundation of Research and Education (FORE) of the American Health Information Management Association (AHIMA) for two complementary projects. The objective of the first project, completed in June 2005, was to examine the state of automated coding software and its development and use to enhance anti-fraud activities.  The second project, completed in September 2005, studied how the use of HIT could enhance and expand fraud management.
Automated Coding Software: Development and Use to Enhance Anti-Fraud Activities
In the first project, researchers identified the characteristics of automated coding systems that have the potential to detect improper coding and the components of the coding process that have the potential to minimize improper or fraudulent coding practices in relation to EHRs.  For this project, FORE conducted literature reviews and interviews with relevant federal agencies and stakeholders on the current state of anti-fraud enforcement and automated coding systems.  This information was used to develop recommendations for software developers and users of coding products to maximize anti-fraud practices.
Report on the Use of Health Information Technology to Enhance and Expand Health Care Anti-Fraud Activities
The objective of this second project is to study how the use of health information technology (HIT) could enhance and expand fraud management. For this five month field based research project, FORE convened a cross industry National Executive Committee to identify the best opportunities to strengthen the fraud management capability of a nationwide interoperable HIT infrastructure. The committee used literature review, cross industry site visits, and interviews to formulate its findings and recommendations. An economic impact model was developed using a Delphi technique and incorporating industry accepted studies to project incremental impact of fraud management under several NHIN implementation scenarios.
2009/12/02
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