When EHR software is developed, vendors don't always consider the state and federal regulations hospitals must comply with, according to RACmonitor.
This disconnect poses a risk for healthcare providers during regulatory audits.
"One hundred percent of provider’s service notes or healthcare records could be noncompliant, based on the underlying software, and the provider would never know," the report reads. "If the provider is accused of failing to report a $1 million overpayment based on a flaw in the software, who bears the burden? The provider? Or the noncompliant software company?"
Here are four common compliance issues found in EHR software.
1. Electronic signatures. Typing the healthcare provider's name at the bottom of a service note is not compliant with Medicare criteria.
2. Self-populating entries. EHR software programs may automatically enter certain information that could be inconsistent with provider notes. For example, software programs may default to the pronoun "he" and if the provider doesn't go back in to change them to "she" for female patients, discrepancies may raise red flags for auditors.
3. Retrospective auto-reporting entries. Some EHR software is programmed to fill in data retrospectively, meaning information was auto-populated before visits as well as after, and that information may be included in subsequent notes as well as notes dating before the visit. This results in inconsistent or inaccurate entries that may peak auditors' interests.
4. Customization to a specialty. Even if a software program includes a platform for a specialty other than the provider's area, leaving data points blank can lead to denials during an audit.
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