This is not uncommon. The OIG has tasked all CMS contractors to pay attention to EMR generated documents and the associated bills, but of course the contractors can't know who is documenting inappropriately, what software, or even if the documentation represents the service. Look at the OIG work list for the past several years. This is addressed frequently, so at some point, surgical centers and their physicians will be looked at. It's up to coders to help educate our providers about how risky this can be.
I'd sit down with your provider and point out any discrepancies, examples of cloning (where every patient's chart looks the same), and blatant errors (this never happened....) and let them know that that is both a compliance issue and a patient care issue. Offer to assist in auditing his documentation within the software and work with the software analysts to make sure that each patient's note represents exactly what happed in the operative session. Then point out that when he signs off on the documentation, he is authenticating under the scope of his license, that the report is valid and accurate, and that he's placing himself at risk if there should be a payer audit, a patient complaint (where the patient recognized that certain things weren't done and complains to the insurance company) or an audit of the surgical center where he performs his surgeries, because they are billing out their surgical services using the same bogus note.
I encourage you to do this in a helpful and non-judgmental manner, because most of the time physicians don't even realize this is an issue. They're all busy, and when the software companies tell them that the documentation practically does it for them, they're all happy about that--then of course, we tell them otherwise. Good luck with this.
