Challenging Healthcare Fraud Charges Due to EHR System Errors

Electronic health record (EHR) systems have become ubiquitous in healthcare, promising improved care coordination, reduced costs, and better health outcomes. However, these complex systems can also lead to unintended errors and vulnerabilities – issues that have legal implications when healthcare fraud charges are involved.

Understanding EHR Vulnerabilities

• Design flaws: EHRs may be poorly designed or configured incorrectly, leading to errors in data recording, retrieval, or analysis. For example, a system might default to old test results instead of recent abnormal findings.[1]
• Technology failures: Complex EHR software can have programming errors, bugs, or hardware problems that jeopardize data. One flaw could impact thousands of records across a healthcare system.[2]
• Implementation issues: How EHRs are incorporated into clinical workflow can introduce risks, even if the technology functions properly. Poor training or mismatched workflows are common problems.[3]
• Usage problems: Well-designed systems can still fail if used incorrectly. Doctors or nurses might input inaccurate information or misinterpret EHR data.[4]

These vulnerabilities can lead to misdiagnoses, treatment delays, medication errors, billing issues, and other problems that undermine care quality and patient safety.[5]

EHR Issues and Healthcare Fraud Charges

When EHR vulnerabilities cause errors, there can be legal implications if healthcare fraud charges are involved. Some common allegations tied to EHR problems include:

• Upcoding: The EHR system might make it easier to inflate billing codes or costs to increase reimbursement. However, EHR flaws could also inadvertently contribute to upcoding.
• Inaccurate records: Data integrity issues might lead to records that are missing information or contain mistakes. Inaccurate records can potentially mask quality of care issues or be used to overbill.
• Withholding records: If EHR vulnerabilities contributed to patient harm, organizations might improperly withhold records from patients or families to conceal problems.

However, there are often reasonable defenses if EHR flaws play a role in healthcare fraud allegations:

Defending Against EHR-Related Fraud Charges

If you face healthcare fraud charges stemming from EHR use, there are proactive legal defenses to explore:

• Lack of intent: You can argue there was no intention to defraud payers or patients if billing errors or data issues stemmed from EHR system vulnerabilities.
• Lack of knowledge: Demonstrate you had no knowledge of EHR software flaws or implementation problems that impacted data integrity or care quality.
• Lack of control: Highlight how you lacked oversight or control over EHR system design, configuration, updates and other factors tied to identified issues.
• Compliance program: Detail the steps your organization takes to prevent, detect, and address EHR problems and fraud through compliance programs, safety checks, employee training and other mechanisms.
• Industry comparisons: Compare your EHR error and fraud rates against industry benchmarks to demonstrate your system and controls are within norms.
• Remediation efforts: Emphasize any efforts to investigate EHR issues once discovered and implement solutions to prevent recurrences.
• Patient impact: Assess and demonstrate how identified EHR problems did not clinically impact patients or lead to overbilling.

These defenses rely on demonstrating good faith use of EHR systems and lack of intent or control over functionality issues. Thorough compliance programs that address EHR vulnerabilities can further strengthen your position.

Avoiding Future EHR-Related Legal Risks

While defending current charges is critical, covered entities can also take proactive steps to avoid future EHR-related legal risks:

• Perform regular risk analyses to identify and address EHR system vulnerabilities.
• Implement comprehensive compliance programs covering EHR safety, security, fraud prevention and detection.
• Provide ongoing EHR and fraud prevention training for all employees.
• Conduct regular EHR safety checks and audits to identify any system issues or problematic usage.
• Have clear processes to investigate, report and address identified EHR problems and vulnerabilities.
• Carefully vet EHR software, vendors and implementation teams to optimize system design and configuration.
• Participate in an EHR user group to share best practices and lessons learned about EHR issues.

Taking these steps demonstrates good faith efforts to prevent EHR problems while optimizing fraud detection. This can strengthen any defenses needed to challenge future healthcare fraud allegations tied to EHR system use.

The Bottom Line

EHR systems aim to improve care delivery but can also introduce unintended vulnerabilities. Resulting errors and inaccuracies have legal implications if healthcare fraud charges are involved. However, covered entities can mount reasonable defenses based on lack of intent, knowledge or control over EHR issues. A proactive compliance program that addresses EHR safety and fraud prevention is the best strategy to defend charges and avoid future risks. With increasing reliance on these technologies, it is critical for healthcare organizations to optimize EHR functionality and usage while safeguarding data integrity.