Fierce EMR today focused on a study of an analysis created by the New England Journal of Medicine that takes a deeper look in to why some of the medical billing today is growing.  In the news of late we have been reading about the government and others questioning the billing and coding of physicians with using electronic medical records.

On many occasions the emergency room is the first stop for treatment, and this can result as patients may not have a regular primary physician and encounters a condition that needs to be diagnosed.  If there are not any prior medical records available it makes sense as it has for years that more diagnosing needs to be done.  New technologies enter the picture and can be more expensive for one aspect.  If no current imaging records and lab results are available then the process has to start somewhere.

If a patient were to be released without a full diagnosis, then the physicians could also be subject to lawsuits for missing the call.  One of the suggested solutions is to allow for more continued education for doctors with proper coding.  As the complexities grow it seems so do the costs.  When it comes to the analytics portions of medical billing the word “fraud” is and has been for years the reason to scrutinize and review medical billing, in other words it is the door opener for accessing some of the records.  We simply today have more chronic conditions to diagnose and better and sometimes more expensive methodologies that what was available a few years ago and thus the number of extended visits will accordingly grow.  CT scanning is cited as assisting in cutting down admissions, but at the same time the cost for care goes up as that expense is now added to the visit.  Overall the imaging does cut down on admissions as a non critical diagnosis is made where as in the past without such, the patient could have been admitted. Below is a chart showing the increase of Level 5 emergency room visits showing the increases with Medicare patients and the impact of imaging and IV fluids from the report in the New England Journal of Medicine.


In many electronic medical record systems automation has made the job a little easier for doctors with using check box style input that are connected to selected billing codes.  This is where the rub comes in with the question of whether or not the system is being “potentially gamed” for additional revenue.  There are many consulting 3rd parties out there working with hospitals that market and sell their services based on helping hospitals to attain the maximum dollars for all visits that are due, based upon services rendered.  As it goes with all software there’s not one “perfect” fit for every scenario so reviewing medical billing records of course will remain as an active process.  Additional training for doctors is certainly a help but when instances of programmatically written systems take over, where does the doctor turn next.

As new technologies and methodologies change and arise for the emergency room, the questions and audits on medical billing will not go away or become simpler any time soon and this analytical process will remain as “work in progress” for a long time.  Certainly “fraud” needs to be eliminated and caught, but the grey areas of analytics giving black and white answers will remain elusive.