Posts Tagged ‘coding’

Hospitals Overbill Medicare and Medicaid by $2 Billion!

May 15, 2012 Leave a comment
Hospitals have been caught overbilling Medicare and Medicaid over $2 billion (what is being reported publicly) over the past decade. Cases of overbilling has risen dramatically over the past two years. According to reports, $106.9 million has been recovered from the hospitals since January 1 of this year. Reasons for overbilling range from being innocent to purely fraud. Failure to comply with federal law and having untrained billing/coding staff seems to be at the root of the problem. However, claiming to have “untrained staff” and pleading ignorance of U.S. federal billing regulations are not excuses that the Office of Inspector General or U.S. Department of Health and Human Services accepts as a valid cause of overbilling the government. Hospitals MUST make sure that all billing/coding staff (internal and external) are properly trained and are completely up-to-date on all federal billing regulations. Internal risk management departments MUST make this compliance and training a TOP priority!  Below is a history of hospitals overbilling Medicare/Medicaid.
California health systems fined $2.3 million  – December 2011 (Source 18)
– improperly billed Medicare for infusion and lithotripsy procedures
California health system fined  $9.1 million   – February 2011  (Source 30)
– submitted false inflated bills for home health services
California hospital system fined $423 million  – January 2007  (Source 31)
-grossly overbilled uninsured and Medicare / Medicaid patients
California hospital fined $8 million                – September 2005 (Source 12)
– tried to bill for an adult day care center and a fundraising resale store
Colorado hospital fined $6.3 million             – January 2012    (Source 6)
– overbilled Medicare by calling patients “inpatients” when they only received outpatient care
Colorado teaching hospital hospital fined $1.2 million                 -September 2001 (Source 13)
-improperly billed for patients hospitalized with pneumonia and angina
CT hospital fined $43,000                                – April 2012 (Source 1)
– overbilled inpatient same-day re-admissions
CT hospital fined $284,773                              – April 2012 (Source 1)
– overbilled due to failure to understand federal billing regulations
CT university hospital fined $475,000            – June 2007   (Source 32)
-overbilled Medicare for cancer treatments
DC teaching hospital fined $659,4000          – April 2012  (Source 2)
– overbilled Medicare due to staff unaware of federal billing regulations
Florida hospital fined $405,000                      – February 2012 (Source 23)
– improperly billed outpatients as inpatients in order to get higher reimbursement
Florida hospital fined $3.9 million                 – February 2012  (Source 4)
-overbilled for kyphoplasty procedure
Florida hospital fined $1,660,134                  – January 2011  (Source 9)
– overbilled Medicare for kyphoplasty procedure
Florida hospitals fined $4.3 million               – February 2003 (Source 10)
– upcoded, submitted false claims
Georgia hospital system fined $2.7 million    – August 2010   (Source 16)
-billed for cross-over claims (patients enrolled in both Medicare and Medicaid at the same time)
Kentucky healthcare system fined $1.3 million  –  August 2011 (Source 19)
-improperly billed Medicaid program in neighboring TN
Kentucky hospital fined $8.9 million              – August 2011     (Source 11)
– overbilled Medicare at higher than justified by the treatment they actually provided
Kentucky health system fined $782,842       – April 2011          (Source 29)
-fraudulently submitted charges for wound care, infusion, oncology services performed in outpatient setting
Illinois hospital fined      $100 million – March 1999   (Source 14)
-upcoded deliberately in order to “bilk” money from government
Indiana teaching hospital fined $1 million    –  May 2012 (Source 17)
-improperly used DRG codes
Massachusetts hospital fined $1.5 million    –   May 2012  (Source 1)
– overbilled outpatient and inpatients
Michigan hospital fined           $260,000         – May 2010         (Source 21)
– overbilled and billed kyphoplasty procedure as an “inpatient” procedure
Mayo Clinic fined $1.26 Million                        – August 2012
– submitted false claims
Minnesota hospital system fined $16 million  – January 2002 (Source 10)
– upcoded, submitted false claims
MO hospital fined $1 million                            – May 2012 (Source 17)
– excess charges for manufacturer credits for medical devices
MO hospital fined   $420,0000                          – October 2011 (Source 27)
-failure to understand and comply with federal billing regulations
NC hospital fined  $6,000           – April 2012  (Source 1)
– overbilled for brachytherapy due to untrained coding staff
NC hospital fined $2 million                            – April 2011          (Source 8)
-overbilled Medicare by ordering higher cost services for patients who only needed outpatient care
NJ hospital system fined $265 million            – June 2006 (Source 25)
-inflated prices for outpatient and inpatient care
NY hospital fined $11.75 million                      – May 2012  (Source 20)
-inflated prices for Medicare patients in order to get higher reimbursements
NY hospital fined $2.3 million                      – April 2012  (Source 5)
– overbilled Medicaid for physician-administered drugs and in trying to turn a profit
NY hospital fined $13.03 million                    – March 2012 (Source 25)
– deliberately “turbocharged” in order to get more outlier fees
NY university hospital fined $995,000                          – October 2011 (Source 28)
– fraudulently overbilled Medicare for urological procedures that were not necessary
NY university hospital fined $88.9 million     – September 2008  (Source 24)
-fraudulently billed Medicare and Medicaid for inpatient detox treatments
TN hospital chain fined $1 million                    – August 2010   (Source 22)
– submitted false claims, billed outpatients as “inpatients”
TN hospital chain fined $1 million                    – August 2010   (Source 22)
– submitted false claims, billed outpatients as “inpatients”
TN hospital chain fined $840 million             -December 2000 (Source 10)
– formerly run by Rick Scott (current FL Gov), upcoding, submitted false claims
TN hospital chain fined  $31 million               – May 2000       (Source 10)
-upcoded, submitted false claims
TX hospital chain fined $42.75 million   – April 2012 (Source 7)
– improperly billed for rehabilitation services
Ohio clinic (major academic clinic)  fined $254,000  –  October 2011  (Source 26)
-failure to understand federal billing regulations
Utah hospitals fined $22 million                    – February 2012 (Source 3)
– overbilled Medicaid by charging emergency level fees for non emergency care
Washington teaching hospital fined $100 million   – August 2011 (Source 19)
-improperly billed Medicare
 Total overbilling fines:   $2,051,475,149 Billion




American College of Healthcare Executives 2011 Survey: Top Issues Confronting Hospital CEOs

February 28, 2012 Leave a comment

The prestigious American College of Healthcare Executives recently released the results of their annual Hospital CEO Survey. 40% of the hospital CEOs responded. For the survey, the CEOs were asked to rank their top issues currently confronting their facility. Financial challenges was the top concern followed by healthcare reform, patient safety, care for uninsured, patient satisfaction, technology, personnel shortages and creating an ACO. ACO and technology were ranked the lowest due to the concern of the high overhead expenses directly associated with them. The issues were then asked to identify specific concerns with in the issues listed above. For analysis purposes, the concerns were divided into three categories: financial challenges, patient safety and quality, and healthcare reform implementation. The results are as follows:

Financial Challenges

– medicaid reimbursement / medicare reimbursement ranked top at 88% of respondents

– Increasing overhead costs (IT, supplies, etc)  ranked at 51%

– revenue cycle management ranked at a low 28%

Patient Safety and Quality

– physician engagement in improving culture and quality ranked top at 72% of respondents

– redesigning space and processes to reduce errors ranked at 43%

– medication errors ranked at a low 31%

Healthcare Reform Implementation

– reducing operating costs associated with implementation ranked top at 67%

– study avoidable readmissions to avoid penalties ranked at 45%

– Hiring physicians ranked at a low 34%

You can read more about the survey in the ACHE’s Healthcare Executive Magazine

American Medical Association AGAINST ICD-10 Implementation

November 16, 2011 Leave a comment

The American Medical Association have voted to fight against the implementation of ICD-10. Many major hospital systems have come out against it stating that it is too expensive to implement.

Healthcare IT News reports that the 65th Interim Meeting of the AMA in New Orleans, in fact, “the AMA House of Delegates voted to work vigorously to stop implementation of ICD-10,” primarily on the grounds that the “timing could not be worse” for this “massive and expensive undertaking” brings too little benefit to physicians, and will prove disruptive as they also work to implement EHRs and demonstrate meaningful use. Citing a 2008 study, AMA explained that projected costs of converting to the unfunded code sets mandate will cost even a three-physician practice $84,000 and slightly more than $285,000 for a 10-physician group.


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