How to Report Electronic Health Records Fraud: What the Software Did and Who Got Paid

To decide how to report electronic health records fraud, speak with our whistleblower experts about the software, the statement made about it and the government payment behind it. You may know why the certification test behaved differently from the released product, who left a favorable reporting error in place, or which drug company’s marketing department helped design a clinical alert. Those are concrete starting points for a case. You can talk with us about your part of the story without having every document in hand.

What Evidence Is Needed to Report Fraud?

Useful electronic health records fraud evidence connects what the software did, what someone claimed about it, the payment and who knew. We trace those connections through product versions, attestations, billing records and internal messages with you.

We distinguish what you personally observed, what someone told you and what you infer from the records. A clinician may know the screen’s behavior while an engineer knows the release history. A sales employee may know the promised return while accounting knows the payment. We work out how those accounts fit.

The first conversation can start with your account and where the records sit. Questions about patient information, screenshots, contractual restrictions or material you handled yourself belong with us and the electronic health records fraud whistleblower counsel we bring into the case.

What Are the Signs of EHR Fraud?

The cases show recurring patterns: a test build with capabilities the shipped product lacked, a usage calculation left favorable to customers, an attestation about work that was never done, or a payment hidden behind a recommendation. Each pattern gives the insider a different connection to explain.

A Passing Test and a Different Product

EHR certification fraud can turn on the difference between software demonstrated to a tester and software delivered to customers. In the historical incentive programs, healthcare providers needed certified technology and had to meet requirements for using it. Developers passed testing by an authorized independent laboratory and obtained certification from an authorized independent certification body. The technical demonstration supported the provider’s claim for payment.

Promoting Interoperability is the later program name. Medicare’s hospital program continues, while the Medicaid program ended in 2021. We assess the software and payment rules that applied to the period you know.

In its 2017 eClinicalWorks settlement announcement, the Department of Justice announced a $155 million resolution with the company and certain employees. It alleged that the company typed the 16 drug codes needed for the certification test directly into its software. The required capability was to retrieve codes from a complete database. We would call that teaching the product the answers to the exam. An engineer who knows how the test configuration differed from production can explain the decision behind the demonstration.

NextGen agreed to a $31 million settlement over alleged certification misrepresentations and paid recommendations. The government’s complaint alleged that NextGen embedded required functions in a temporary version of its separate Knowledge Based Model software for testing. The complaint alleged that released versions, including 5.8.0.77 and 5.8.3, lacked required functions such as recording vital signs and creating referral summaries.

The complaint connected those versions to Medicare incentive reporting periods from 2014 through 2016 and Medicaid periods from 2014 through 2017. That is why a version identifier matters: it connects the behavior someone observed to the product and payment period the government is examining.

The Dashboard Counted What Helped Customers Get Paid

A usage dashboard can supply the figure a provider relies on for an incentive attestation. The $57.25 million Greenway Health settlement in 2019 included an allegation that an earlier version of Prime Suite incorrectly calculated the percentage of office visits followed by a clinical summary. The Justice Department alleged that Greenway knew about the error and refrained from correcting it so users would receive incentive payments.

The government’s eClinicalWorks complaint quoted an employee confronting a similar counting problem:

United States ex rel. Delaney v. eClinicalWorks LLC, government’s complaint in intervention, paragraph 77, quoting an employee’s internal message.

That message gives the allegation something a screenshot alone cannot: an account of what the company knew about the calculation. The denominator, the person who recognized the problem and the decision about correcting it belong in the same conversation.

The Attestation Outran the Work

False meaningful-use attestations put the provider’s statement beside the work claimed to support it. In Coffey Health System’s 2019 settlement, the hospital agreed to pay $250,000 to resolve allegations that it falsely attested to conducting or reviewing security risk analyses for the 2012 and 2013 reporting periods. The government alleged false claims to Medicare and Medicaid. The Department of Health and Human Services’ Office of Inspector General and the U.S. Attorney’s Office for the District of Kansas investigated the case.

For someone inside a hospital, the comparison is concrete: the attestation, the analysis it described, when that analysis was performed or reviewed, and the payment sought. We assess those records together with the account of whoever knew what work had actually been done.

A separate criminal case shows that connection from the submitter’s side. In his guilty plea, Shelby Regional Medical Center’s former chief financial officer admitted making a false meaningful-use statement to Medicare. The Justice Department’s announcement described a statement that produced a $785,655 payment to the hospital. His responsibilities included overseeing electronic health records implementation and attesting to its meaningful use.

The Clinical Note Became Support for a Bill

EHR billing fraud follows the record into the charge. A copied examination, a prefilled template or a changed note can supply apparent support for upcoding: billing for a higher level of service than the work performed. For a clinician or billing employee, we examine the encounter, the source text, the generated note, signing and amendment history, and the code or claim that followed.

The Centers for Medicare & Medicaid Services’ June 2016 fact sheet, Documentation Integrity in Electronic Health Records, identified cloning and copy-and-paste features among those improperly used to facilitate fraud, waste and abuse. It also described how autofill from macros and templates can create unintended documentation errors. Its focus extended to authorship, amendments, corrections and auditing documentation when submitting reimbursement claims. That puts the clinical record and the billing record in the same investigation.

The 2022 Vassar College thesis A Panacea or a Problem? Electronic Health Records and the Complicated Politics of Its Stakeholder Network describes the tension between the many uses of standardized records and the recording burden borne by caregivers. For our review, that means listening to the people entering health care information as well as those turning it into a charge.

An audit trail needs that human context too. The government’s eClinicalWorks allegations included inaccurate recording of user actions in audit logs. We examine what a particular system recorded alongside the note, the workflow and the witness’s account. The product’s name alone cannot tell us what a particular log captured.

A Clinical Alert Had a Paying Sponsor

Paid influence can sit inside the clinical workflow. Under its criminal deferred prosecution agreement, Practice Fusion admitted receiving kickbacks from an opioid company in exchange for using its electronic health records software to influence prescribing. The criminal information described a nearly $1 million payment solicited for an alert intended to increase prescriptions of extended-release opioids. The sponsor’s marketing department financed the payment and helped design the alert. Practice Fusion marketed the expected prescribing return.

We see a sales campaign arriving at the exact point where a clinician expects clinical guidance. For a product or commercial insider, the sponsor agreement, design communications, alert wording, trigger and payment explain how that happened.

Practice Fusion separately agreed to approximately $118.6 million in civil settlements resolving kickback and certification allegations, including thirteen other sponsored alert arrangements. Those allegations included missing data-export functionality and disabling access to an export feature after certification.

The Customer Recommendation Came With a Contract

Purchasing and referral arrangements can carry the evidence outside the software itself. In the $3.8 million CareCloud settlement announcement in 2021, the government alleged that the Champions Program paid existing clients through credits, bonuses and percentage success payments to recommend its products. The government alleged that participants signed agreements prohibiting negative information about CareCloud’s software. Prospective customers were not told about the compensation or that restriction, according to the allegations.

A glowing reference with the criticism contractually removed. The purchasing employee who heard it and the commercial employee who arranged it may know different halves of the same pitch.

The 2022 Modernizing Medicine settlement joined another set of transactions. The Justice Department alleged that the vendor accepted payments from Miraca Life Sciences to recommend its pathology services, worked with the laboratory to donate electronic health records systems to providers to increase laboratory orders and software customers, and paid for recommendations of its own product. The alleged arrangements connected the laboratory’s orders to the vendor’s sales. We examine the agreements, subsidies, recommendations and payments together.

Can a Whistleblower Report EHR Fraud?

Yes. Electronic health records whistleblower cases have begun with people inside a vendor and people using its product at a customer organization. The eClinicalWorks case began with a software technician formerly employed by a municipal health agency. The NextGen case began with a registered nurse and a nurse practitioner using the software in their work for the South Carolina Department of Corrections. Modernizing Medicine’s whistleblower was a former vice president of product management.

Those vantage points matter. A customer can describe what happened during clinical use. A product employee can explain an internal capability decision. Someone involved in purchasing can explain what a paid reference left out. We build the assessment around the work you know and the decisions you can explain.

How We Help You Report Electronic Health Records Fraud

We assess the reporting approach with you, starting with the conduct and the federal payment it affected. A qui tam case under the False Claims Act allows a private party to pursue false claims on the government’s behalf and share in a recovery. Our role is to evaluate the software and payment evidence with you and bring in electronic health records fraud whistleblower lawyers who understand the technical and payment issues your case presents.

Access and export concerns also belong in this conversation. For an access obstruction, we examine the organization controlling the information, what was requested and what happened, alongside any certification representation or payment connection. We handle the choice of approach with you.

If your concern is how to report electronic health records fraud anonymously, bring that question to our experts. Confidentiality, an earlier internal report or your own part in a decision are matters we work through with you and your whistleblower counsel.

How Much of a Settlement Does a Whistleblower Get?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

Modernizing Medicine agreed to a $45 million settlement. The Justice Department announced approximately $9 million for the former product-management executive who brought the case.

Your Knowledge, Our Whistleblower Expertise

If you know which release lost a required function, which attestation outran the work or who paid for a recommendation, speak with our whistleblower experts about building your strongest electronic health records whistleblower case. We connect the technical facts to the money and the decisions, bring in electronic health records fraud whistleblower lawyers suited to the case, and stand beside you throughout it.