State and federal governments are using advanced technology to find suspicious billing patterns that would indicate upcoding or unbundling, and when they find suspicious patterns, they aren’t just looking at the documentation.
MedStar Health System’s Good Samaritan Hospital agreed to pay $793,548 to settle allegations that it submitted false claims to the to federal benefit programs from 2005-2008. They deny any wrongdoing and have released a statement saying the hospital “is committed to the highest quality of patient care. While we have always maintained that we have provided the highest level of quality care to our patients in accordance with all laws and regulations, we have chosen to resolve this matter with the government in order to focus on providing safe, effective, quality patient care and treatment.”
In 2005 Maryland Health Services Cost Review Commission, which sets the rates in the state that must be paid by insurers, changed a rule to allow higher reimbursement for more severe secondary diagnoses. Federal officials claimed the hospital staff used leading questions so doctors would report malnutrition in the patients record, leading to the higher reimbursement rate.
Even if your documentation supports the coding your claims aren’t necessarily safe. Are your policies and procedure putting you at risk? If you have a process in place that causes an over-utilization it will raise a red flag with government audits and might put you at risk for False Claims allegations.