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, 911³Ô¹Ï 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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In a nutshell, MAOs will now have the same protections and rights as the Centers for Medicare and Medicaid Services (CMS).

Humana, the MAO in this case, argued that the plain language of the Medicare Secondary Payer (MSP) statute afforded them a broad right to use the Federal Court to recover funds they paid on their enrollee’s behalf. Additionally, the MSP provisions mandated that any recovery be in the form of double damages. The appellate court agreed.

This opens up another avenue for suits and damage recoveries. Savvy and efficient MAO companies now have a very clear incentive to go after primary payers – including workers’ compensation, auto and liability carriers – to maximize their profitability. This makes it even more important for primary payers to have a buttoned up MSA compliance process.

The post MSA Fines – Recent Ruling Adds More Risk appeared first on 911³Ô¹Ï.

The University of California San Francisco researchers set out to find out how much an appendectomy cost in California. The price varied from $1,529 to $182,955.

The “recovery room” was over $7K for 2 hours. This room charge has always driven me nuts. For an inpatient stay, the patient already has a room they are paying to stay, sleep and “recover” in. That room rate does not get reduced when they are also charged for the “surgical room” to do the surgery, and then they throw in another room or two for “recovery” at massive hourly rates well beyond the cost.

The hospitals cite issues caused by Medicare, Medicaid, and other government programs, stating “…a more straightforward pricing system is only possible when reimbursement from government-sponsored patients covers actual costs.” They are flat out admitting they are cost-shifting to every other person who treats there to cover government plans. From what I’ve seen, many Medicare payments are well above what reasonable costs should be; however, there is likely some validity to this point as I’m sure some payments are unreasonable.

Making pricing transparent (fair to all parties) is critical to the long-term survival of healthcare. 911³Ô¹Ï’s surgical care program resolves all of these issues, eliminating the variability, moving treatment out of the arbitrary hospital system, and paying providers a fair rate, quickly.

The post Variability in Surgical Costs – Bill Goes Viral appeared first on 911³Ô¹Ï.

As patients have their Medicare payments denied, they will start coming back to their attorneys or payers who handled their workers’ compensation, auto or liability claims and will start demanding help with compliance. This will create more awareness over time for the need for POST settlement compliance and will drive up the percentage of claims that require MSA administration assistance.

If you are a payer and do not have processes to assist claimants with post settlement MSA administration, it is time to put this solution in place.

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