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ICD-10 Implementation To Cost Physicians and Hospitals Millions

July 31, 2012 1 comment

ICD-10 implementation is expected to happen now (after delays) in October 2014. The American Medical Association and Medical Group Management Associations state that implementation will cost a single  physician $27,000 – $29,000. This amount of money could potentially be detrimental to a physician ‘s (and even a hospitals) bottom line. Below is how much ICD-10 could potentially cost physicians (and hospitals). The calculations you will find below are based upon the number of physicians a facility has. Here is what some of our nation’s top hospitals might pay.

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Cleveland Clinic                                                  –       $70,000,000   – $75,000,000

Duke Medical Center                                         –       $39,000,000    – $42,000,000

Emory University Hospital                              –       $27,000,0000  – $29,000,000

Johns Hopkins Hospital                                 –        $57,000,000     – $62,000,000

Massachusetts General Hospital                  –       $48,000,000 – $51,000,000

Mayo Clinic                                                         –        $99,000,000   – $107,000,000

Northwestern Memorial Hospital                 –        $48,000,000  – $51,000,000

NY Presbyterian Hospital                                –      $165,000,000  – $178,000,000

Ochsner Health System                                   –       $25,000,000    – $27,000,000

Texas Medical Center                                        –      $540,000,000  – $580,000,000

UCLA Medical Center                                        –       $52,000,000    -$56,000,000

Vanderbilt University Medical Center          –      $324,000,000  –  $348,000,0000

Health Insurance Company Scheme Alert: Downcoding

June 28, 2012 Leave a comment

Physicians are finally beginning to drop insurance carriers due to the downcoding “scam” that insurers are using in order to greatly enhance their profits. Downcoding specifically is when an insurer unilaterally decides after services have been rendered to reduce the amount of reimbursements a physician (even hospital) can receive. According to the American Medical Association, most physicians believe this practice is a scam aimed directly at giving insurers as much profit as possible and this specific issue is what physicians complain to the AMA the most about.
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CPT Codes Most Downcoded by Insurance Company:
Code:                                                    Medicare Rate:                                         Usual Downcoding Amount
99205 (new pt office visit)               $213.60
99204 (level 4 new office visit)       $170.47                                                      $43.13
99203 (leve 3 new office visit)         $110.92                                                       $59.55
99202 (level 2 new office visit)        $76.88                                                        $34.04
99201  (level 1 new office visit)        $44.77                                                         $32.11
99215  (level 5 established patient)  $149.60
99214  (level 4 established patient)  $111.39                                                      $38.21
99213  (level 3 established patient)   $74.46                                                      $36.93
99212  (level 2 established patient)   $44.77                                                      $29.69
99211 (level 1 established patient)     $22.39
9234 (outpatient observation)            $142.68
99233 (level 3 hospital progress note)   $108.67                                                $34.01
99232 (level 2 hospital progress note)   $75.78                                                  $32.89
99231 (level 1 hospital follow up)            $42.12                                                  $33.66

Average % difference between usual downcoding amount and normal Medicare rate is 49%.
( Source 2)
—————————————————————————————————————————————— Aetna
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– Paid $6,270,000 settlement for downcoding dentist claims  (Source 3)
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Blue Cross Blue Shield
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– downcoded Anesthesiologist claims (Source 4)
-downcoded Urologist claims in Kansas (Source 4)
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Humana
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Physician exposes massive  “scam” run by Humana (Source 1)
– Humana underpaid by $108.47 on code 99215 when should have paid $149.60
-Humana underpaid by  $27.13 on code 99213 when should have paid $74.46
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Sources:

1. http://www.wejonesmd.com/Pages/Ins/humana.html
2. http://www.mtbc.com/learningcenter/index.php/steps-your-practice-can-take-to-prevent-downcoding-on-medical-claims/
3. http://articles.baltimoresun.com/2003-08-20/business/0308200151_1_aetna-dentists-dental-association
4. http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/litigation-center/case-summaries-topic/managed-care-payments.page

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Keywords: medical coding, medical billing, health care insurance, health plan, united healthcare, humana, blue cross blue shield

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.
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BY STATE
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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
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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
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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
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DC teaching hospital fined $659,4000          – April 2012  (Source 2)
– overbilled Medicare due to staff unaware of federal billing regulations
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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
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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)
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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
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Illinois hospital fined      $100 million – March 1999   (Source 14)
-upcoded deliberately in order to “bilk” money from government
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Indiana teaching hospital fined $1 million    –  May 2012 (Source 17)
-improperly used DRG codes
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Massachusetts hospital fined $1.5 million    –   May 2012  (Source 1)
– overbilled outpatient and inpatients
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Michigan hospital fined           $260,000         – May 2010         (Source 21)
– overbilled and billed kyphoplasty procedure as an “inpatient” procedure
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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
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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
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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
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NJ hospital system fined $265 million            – June 2006 (Source 25)
-inflated prices for outpatient and inpatient care
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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
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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
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TX hospital chain fined $42.75 million   – April 2012 (Source 7)
– improperly billed for rehabilitation services
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Ohio clinic (major academic clinic)  fined $254,000  –  October 2011  (Source 26)
-failure to understand federal billing regulations
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Utah hospitals fined $22 million                    – February 2012 (Source 3)
– overbilled Medicaid by charging emergency level fees for non emergency care
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Washington teaching hospital fined $100 million   – August 2011 (Source 19)
-improperly billed Medicare
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 Total overbilling fines:   $2,051,475,149 Billion
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Sources:

16. http://law.ga.gov/00/press/detail/0,2668,87670814_156273695_162528998,00.html

19. http://theidentityadvocate.uplog.org/2011/08/18/overbilling-a-leading-cause-of-healthcare-fraud/

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.

Source: http://www.healthcareitnews.com/news/ama-mounts-campaign-halt-icd-10

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