Health Information Management

Don’t remain silent if you observe a pattern of fraudulent conduct

HIM-HIPAA Insider, August 16, 2011

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It started with two courageous coders who knew the query process at Johns Hopkins Bayview Medical Center, Inc., in Baltimore, where they worked, wasn't quite right-or compliant.

Specifically, the hospital employed a physician who worked in the billing department to review clinical documentation and increase reimbursement by increasing the severity of the secondary diagnoses recorded for certain patients. The physician focused on laboratory test results that could have indicated the presence of a complicating secondary diagnosis (e.g., malnutrition or respiratory failure). The physician advised treating physicians to include such a diagnosis in the medical record, even if the condition had not been diagnosed or treated during the hospital stay.
At first, the coders, who were well aware of their ethical obligations not to lead physicians, complained about the unethical practice internally. When nothing was done, they complained to HHS. When still no action was taken, they decided to file a federal lawsuit against Bayview under the False Claims Act. They asserted that the hospital reported false diagnoses to the Maryland Health Services Cost Review Commission over a 20-month period between July 1, 2005, and February 28, 2007.
The outcome? Bayview agreed to pay the Medicare Trust Fund $2.75 million to settle the lawsuit. The settlement agreement also provided that the coders who filed the complaint that prompted the federal investigation receive 20% of the total settlement (i.e., $550,000).
Editor’s note: To read more, access this article in the August issue of Briefings on Coding Compliance Strategies.

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