Report: Build antifraud measures into health IT

Two reports on health IT and fraud

A national network for exchanging digital health information can reduce the incidence of health care fraud, a panel of experts said yesterday, but antifraud measures must be built into the network from the start.

Using built-in analytical tools, insurance companies and government agencies could detect fraud schemes before they issue reimbursement payments to patients or health care providers, the panel said.

The American Health Information Management Association’s Foundation of Research and Education, with support from the Office of the National Coordinator for Health Information Technology, convened the panel.

The foundation issued two reports: “Use of Health Information Technology to Enhance and Expand Health Care Anti-Fraud Activities” and “Automated Coding Software: Development and Use to Enhance Anti-Fraud Activities.”

“The Nationwide Health Information Network policies, procedures and standards must proactively prevent, detect and support prosecution of health care fraud rather than be neutral to it,” the health IT report states.

The 22-member panel recommended that public-key encryption and other security tools be used to ensure that information is transmitted via the network securely, with strong privacy protections. Panelists listed biometric authentication as one option for ensuring such security.

They said that all transactions should be traceable to their originators, systems should be redundant in case of failure and records should be stored for at least 10 years.

At the same time, the panel said the antifraud measures should not be unduly expensive or disruptive for users. “Data required from the NHIN for monitoring fraud and abuse must be derived from its operations and not require additional data transactions,” panelists said.

Although many people say patients should be allowed to opt out of participation in exchanges of their health information among doctors, insurance companies, hospitals and others, the report cautions that “those who are the most aggressive perpetrators of fraud will almost certainly opt out of the NHIN in order to avoid its antifraud capabilities.”

The panel acknowledged that if the network were beginning to operate now, all the necessary fraud-fighting tools would not be in place. “While many of the recommendations cannot currently be implemented, they identify the future technology, capability and capacity that will be needed,” said Dr. Donald Simborg, a consultant and co-chairman of the panel.

Use of automated coding software is one way to reduce fraud, according to the second report. Such software scans the text of a digital patient record and generates codes for billing based on diagnoses and services rendered. Currently, people need to review bills that automated coding systems generate.

Health care fraud reportedly costs at least $51 billion a year. It can take the form of billing for procedures not carried out and diagnosing patients as having new ailments or ones more than they really are.