The Department of Justice and the HHS Office of Inspector General have formed a False Claims Act Working Group to prosecute civil health care fraud, and one priority is manipulation of EHRs for inappropriate use of Medicare-covered services. Recent legal cases highlight the risks associated with EHR systems that lack proper oversight and compliance functions, particularly for features like automated diagnosis coding tools. Health care organizations should monitor their own claims for outliers and investigate concerns raised by clinicians and administrative staff, write attorneys with Holland & Knight.

Pharmacy owners Thomas Weir, William Donaldson and Pamela Spivey of Celina, Tenn., have pleaded guilty to health care fraud and illegal distribution of controlled substances. According to prosecutors, they dispensed large volumes of opioids from 2014 to 2019 despite signs of abuse and billed Medicare and TennCare for fraudulent prescriptions, in addition to participating in a kickback scheme.

Felix Mercedes, of Worcester, Mass., has pleaded guilty to leading a scheme that stole personal information from vulnerable individuals to fraudulently bill MassHealth for more than $500,000 in home health services that were never provided. Mercedes was sentenced to one to three years in prison and five years of probation, and he was ordered to pay $500,000 in restitution.

The HHS Office of Inspector General has released a data snapshot on remote patient monitoring billing patterns, following its initial report last year that identified program integrity concerns. The new data found that about 99% of practices showed no problematic billing patterns, but those with issues saw sudden spikes in new patient enrollment and a lack of prior patient relationships, among other concerns.

Health system leaders are integrating artificial intelligence into existing strategic initiatives, focusing on tangible outcomes like reducing documentation burdens and improving access, according to interviews with AI and informatics leaders at multiple health systems. "AI should be embedded into whatever your strategic projects are or whatever problems are being solved at the health system level," said Deepti Pandita, chief medical information officer and vice president of clinical informatics at UCI Health.