Performance Improvement 2008. What is the Scope of the Health Care Fraud Problem that Using Electronic Health Records Can Help Reduce?


This study sought to enhance data quality in and develop anti-fraud requirements for electronic health records (EHRs). A panel of experts in the private and public sectors developed recommendations validated through public comment. Health care fraud has been a significant and growing concern for the country and fighting health care fraud is a priority for the Federal government and the private sector. The health care sector and the Federal Government continue to embrace interoperability and electronic health records to reduce medical errors and improve cost-effective delivery of care.

In 2005, the United States spent $2 trillion or 16 percent of its Gross Domestic Product, on health care. The National Healthcare Anti-fraud Association, a not-for-profit organization that has health care anti-fraud experts from both the public and private sectors noted that, although fraudulent claims were a small percentage of overall claims, they accounted for between 3 percent and 10 percent of total claim dollars, or a range of $60 to $200 billion dollars. Recommendations included the following:

  • Require a standardized audit log that supports both security risk and anti-fraud management;
  • Demonstrate the ability to generate and embed a document ID tracking number for patient chart outputs or exports, unique for each instance when a patient chart output or document is printed, electronically communicated, or otherwise exported from the electronic health record; and
  • Require a traceable and auditable path from a claim payment or a transmission of a pay for performance payment to the clinical documentation supporting the claim.

Report Title: Enhancing Data Quality in Electronic Health Records,
Agency Sponsor: OS-ONC, Office of the National Coordinator for Health Information Technology
Federal Contact:
Kathleen Fyffe, 202-205-0670
RTI International

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"PerformanceImprovement2008.pdf" (pdf, 1.29Mb)

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