medical bill review Archives - 911�Թ�

Upcoding Crackdown: Federal Efforts Fail to Benefit Private Insurers

Jason Beans — Thu, 18 Jan 2018 15:49:48 +0000

For more than a decade, taxpayer-funded health care programs have seen a steady uptick in higher-paying billing codes. Office visits, outpatient services, and emergency room care have all been billed at progressively higher reimbursement codes, raising fees by billions of dollars.

Many providers contend the shift is the result of sicker patients coupled with the widespread implementation of electronic medical records, as treatment and documentation of more complex cases requires greater time and effort. But the persistent increase in costlier codes has made pursuing potential billing abuse a Justice Department priority.

One area of focus for federal investigators has been upcoding, the practice of deliberately billing for more extensive and costly services than were actually performed.

In February 2017, nationwide hospital staffing provider TeamHealth Holdings agreed to plus interest to settle allegations that its hospitalist group practice, IPC Healthcare, submitted upcoded bills to Medicare, Medicaid, the Defense Health Agency, and the Federal Employee Health Benefits Program.

In June 2017, Carolinas Healthcare System agreed to to resolve allegations that it billed federal health care programs for “high complexity” urine drug tests when the tests conducted were only of “moderate complexity.” According to court documents, this upcoding persisted for four years and cost the government an extra $80 per test.

In October 2017, multi-location New York Spine & Wellness Center agreed to to resolve improper billing claims after a federal inquiry determined the practice routinely billed for moderate sedation services – which require physicians spend at least 16 minutes with patients – despite its doctors not meeting the minimum time criteria.

But upcoding is not exclusive to tax-payer funded health care. In the case of New York Spine & Wellness Center, for example, a private insurer first detected the Center’s sedation upcoding in January 2015, initially rejecting two claims that fell short of the 16-minute rule. A subsequent audit by the same insurer resulted in more rejections, but the Center continued its upcoding abuse for two more years until the U.S. Attorney’s Office intervened, seeking to recover overpayments by the state’s Medicaid program. Indeed, of the $1.9 million settlement, more than $660,000 will be returned to the New York Medicaid coffers.

Outcomes such as these are terrific news for taxpayers, but such retrospective vigilance by the Feds has little to no impact on private insurers, employee organizations, and individual payers.

While the government concentrates on recouping federal dollars post-payment, medical cost containment firms must protect private payer clients from overpaying upfront. For example, 911�Թ� uses tools such as in-depth bill review by certified coders and nurse auditors and pre-negotiated, bundled rates to wean out upcoding and other billing abuses on a transactional level. Such proactive approaches are a key core competency of medical cost management, and continue to be as important today as they have been historically.

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EMRs: The Law of Unintended Consequences

Jason Beans — Tue, 09 Oct 2012 13:20:00 +0000

The government has been pushing for electronic medical record keeping for many years. The thought was it would drive efficiencies, reduce costs and improve care. Billions in incentives have been spent trying to get hospitals and providers to upgrade their systems to allow for electronic medical record keeping.

This shows that Medicare is finding much higher billing increases from the providers with electronic medical records than those without it. The main reason is the new systems allow for easy “upcoding” of services.

Some examples include: the emergency department Faxton St. Luke’s Healthcare in Utica, NY with a 43 percent increase in patients “needing” the highest levels of treatment the first year the hospital began using electronic health records. Baptist Hospital in Nashville, TN saw an 82 percent increase in the highest-paying claims the year after the hospital started using a software system for emergency room records.

In a whistle-blower lawsuit filed in 2007, Dr. Alan Gravett, a former emergency room physician, contended that these techniques drove Medicare reimbursement levels substantially. When Methodist Medical Center of Illinois in Peoria rolled out an electronic records system in 2006, Gravett, said the new system prompted doctors to click a box that indicated a thorough review of patients’ symptoms had taken place, even though the exams were rarely performed. Another function let doctors pull exam findings “from thin air” and include them in patients’ records. When it’s electronic, cut and paste with “pre-filled text” is easy. Methodist’s Medicare billings for the highest level of emergency care jumped from 50 percent of its emergency room Medicare claims in 2006 to more than 80 percent in 2010, making the 353-bed hospital one of the country’s most frequent users of high-paying evaluation codes. We all intuitively know the 50 percent is likely inflated, and the 80 percent is just not possible.

Many of these programs can automatically generate detailed patient histories, or allow doctors to cut and paste the same examination findings for multiple patients — a practice called “cloning” — with the click of a button or the swipe of a finger on an iPad, making it appear that the physicians conducted more thorough exams than, perhaps, they did.

The New York Times article cites many examples, facts, statistics and studies showing how this catastrophic issue is becoming even more prevalent. 911�Թ� must stay on the look-out for this trend of cloned medical records and patients must start being on the alert for overbilling. One patient in the article took action on an instance of overbilling. The patient was seen in the emergency room of a Virginia hospital for a kidney stone. When he received the bill from the emergency room doctor, his medical record — produced electronically — reflected a complete physical exam that never happened, allowing the visit to be billed at the highest level. Ultimately, the only thing that can stop this abuse is more consumer involvement.

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We Are Creating Another Problem

Jason Beans — Thu, 05 Jul 2012 14:24:00 +0000

I have often written about the issues caused by our medical industry with opioids. We are creating addicts that in turn create unsatiable and recurring demand.

As society sees the issues and takes action, some people will clean up and some will search for a way to satiate the addiction.

One well-known and affordable source of the opioid high is heroin. It appears that this transition is as a new wave of heroin addiction is being spawned by the crackdown on painkiller abuse.

We all know how hard it is to get off the dragon. The key is to make sure we have the systems and processes in place so people do not become addicted in the first place.

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Transparency in Medical Bill Review

Jason Beans — Mon, 25 Jul 2011 15:30:00 +0000

Here’s a 911�Թ� article . It’s on the importance of transparency in a bill review program.

Transparency is about trust. It’s amazing to me how often I find programs with hidden or misleading data, and the client tolerates that behavior. At 911�Թ�, if our partner isn’t transparent and open, then that partner is not going to be part of our mix for long.

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Some Appreciation for Coding

Jason Beans — Fri, 17 Jun 2011 21:05:00 +0000

Most of us have looked at our medical bills with confusion. I did when I had medical bills piling up. It is a separate language and art form to understand healthcare billing in our society. It is critical that someone look at your billing. It is a sad fact that many medical providers are more profitable from their billing prowess than their medical outcome prowess.

Catching one issue during medical bill review can make a huge impact on the claim. shows some appreciation for the area we at 911�Թ� try to be the best at: coding. It also shows the importance of catching relatedness for the carrier, for non-group health claims (work comp, auto, etc.). It is critical that payors or patients review bills closely. If using a bill review company, it’s crucial that bill review companies check to see if the injury is really related to the claim. Reviewing relatedness and checking coding results is a huge cost difference to clients and the healthcare system at large.

That is money that can better be spent expanding companies and creating jobs, covering more people, or just savings for retirement. This issue is critical to all of us.

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