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Posts Tagged ‘revenue cycle management’

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
————————–
– downcoded Anesthesiologist claims (Source 4)
-downcoded Urologist claims in Kansas (Source 4)
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Humana
———————————-
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

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Health Insurance Companies Fined $940 Million for Failing to Reimburse Physicians

June 24, 2012 Leave a comment
Health insurance companies  routinely do not reimburse physicians on purpose in order to protect company profits. This problem has skyrocketed over the past decade alone. During this particular time period, One hundred nine companies were fined $940,445,363 for failing to pay physicians in a timely manner.  States gave 104 companies 455 fines totaling $156,951,581.   Forty four are non-profit and they were fined 170 times totaling $62,030,981.  Sixty five are for-profit and they were fined 285 times totaling $94,920,600.  Ten for-profit companies had federal ERISA settlements against them which totaled $784,855,000. Blue Cross Blue Shield had the most fines of the non-profit sector which totaled $54,645,878. UnitedHealthcare was fined the most of the for-profit sector which totaled $417,514,675.
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Not-for-Profit
————————————————————————————————————————-
Affinity
# of State Fines:   5
Total State Fines:  $30,900  (Source 1
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Alameda Alliance
# of State Fines:    1
Total State Fines:  $333,229    (Source 1
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Blue Cross Blue Shield
# of Fines:   43
Total State Fines:  $54,645,878  (Source 1
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Capital District Health Plan
# of State Fines:    6
Total State Fines: $55,700  (Source 1
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Centercare
# of State Fines:  3
Total State Fines: $8,200  (Source 1
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Community Choice
# of State Fines:  2
Total State Fines:  $10,300   (Source 1
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Community First Health Plans
# of State Fines:    1
Total State Fines:  $200,000    (Source 1
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Community Health Plans of NY, Washington
# of State Fines:    4
Total State Fines:  $1,005,200  (Source 1
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Community Premier Plus
# of State Fines:    1
Total State Fines:  $1,200    (Source 1
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Fidelis
# of State Fines:    5
Total State Fines:  $10,100  (Source 1
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FreeState
# of State Fines:    1
Total State Fines:  $7,500  (Source 1
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HM Health Insurance
# of State Fines:   1
Total State Fines:  $500 (Source 1
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Group Health Cooperative
# of State Fines:    15
Total State Fines:  $57,050 (Source 1
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Health Services Med Corp
# of State Fines:    1
Total State Fines:  $7,300 (Source 1
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Healthcare Underwriters Mutual
# of State Fines:    1
Total State Fines:  $9,750  (Source 1
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HealthNow (Medicare Advantage)
# of State Fines:    12
Total State Fines:  $1,170,300 (Source 1
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Health Plus
# of State Fines:    3
Total State Fines:  $75,200  (Source 1
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Healthsource plan of NY/NJ
# of State Fines:    2
Total State Fines:  2,200 (Source 1
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Heritage Provider Network
# of State Fines:    2
Total State Fines:  $294,000  (Source 1
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HM Health Insurance
# of State Fines:   1
Total State Fines:  $500 (Source 1
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Hometown Health Plan
# of State Fines:    1
Total State Fines:   $25,000 (Source 1
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Indemnity Insurance Company
# of State Fines:    1
Total State Fines:  $1,800 (Source 1
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Independent Health Association
# of State Fines:   5
Total State Fines:  $49,775 (Source 1
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Inland Empire
# of State Fines:    1
Total State Fines:  $2,500  (Source 1
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Inter Valley
# of State Fines:    1
Total State Fines: $7,500   (Source 1
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JMH Health Plan
# of State Fines:    1
Total State Fines:  $25,000 (Source 1
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Kaiser Foundation Health Plans
# of State Fines:    13
Total State Fines:  $792,800 (Source 1
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Lifewise Health Plan
# of State Fines:    1
Total State Fines:  $1,250 (Source 1
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Managed Health Network
# of State Fines:    2
Total State Fines:  90,000  (Source 1
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Mayo Health Plan
# of State Fines:    1
Total State Fines: $25,000  (Source 1
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Med Mutual of Ohio
# of State Fines:    1
Total State Fines:  $100,000 (Source 1
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Mercy Health Plans
# of State Fines:    1
Total State Fines:  $100,600 (Source 1
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Molina
# of State Fines:    1
Total State Fines:  $5,000 (Source 1
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MVP Health Plan
# of State Fines:    3
Total State Fines: $35,000  (Source 1
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Promina Health Plan
# of State Fines:    1
Total State Fines: $81,635  (Source 1
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Providence Health Plan
# of State Fines:    2
Total State Fines:  $3,750 (Source 1
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Sharp Health Plan
# of State Fines:    1
Total State Fines:  $20,000  (Source 1
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Sloans Lake
# of State Fines:    1
Total State Fines:  $156,750 (Source 1
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St. Barnabus (Partners in Health)
# of State Fines:    1
Total State Fines:   $1,300 (Source 1
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St. Joseph’s Care Management
# of State Fines:    1
Total State Fines:  $33,538 (Source 1
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SummaCare
# of State Fines:    1
Total State Fines:   $125,000 (Source 1
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Unicare Life
# of State Fines:    6
Total State Fines:  $1,533,426 (Source 1
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Univera / Health Plan Inc (NY)     NP
# of State Fines:    2
Total State Fines:  $24,550 (Source 1
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Vytra
# of State Fines:   9
Total State Fines:  $483,800 (Source 1
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For-Profit
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Aetna  (Public Traded)
# of  State Fines:     31
Total State Fines:  $8,262,982  (Source 1
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American Heritage Life (AllState, Publicly Traded)
# of State Fines:  2
Total State Fines: Fined $264,765  (Source 1
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American Medical Life
# of State Fines:     1
Total State Fines $1,000       (Source 1
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Amil International Insurance Company
# of State Fines:   2
Total State Fines  $196,543  (Source 1
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Alta Health and Life
# of State Fines    1
Total State Fines: $250  (Source 1
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Avemco Insurance
# of State Fines:   2
Total State Fines: $269, 729  (Source 1
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Beacon Health Plan
# of State Fines: 1
Total State Fines: $50,000    (Source 1
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Capitol American Life
ERISA Settlement:  $6,826,000 (Source 6
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Careplus
# of State Fines: 4
Total State Fines:  $28,345  (Source 1
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Central Reserve Life
# of State Fines:  2
Total State Fines:   $811,513 (Source 1
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CHA HMO
# of State Fines:  1
Total State Fines:  $43,750   (Source 1
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Cigna (Publicly Traded)
# of State Fines:    26
Total State Fines:  $4,954,534 (Source 1
ERISA Settlement:  $954,000  (Source 6
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Combined Insurance Company of America of Illinois
# of State Fines:  1
Total State Fines:  $30,000   (Source 1
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Conseco Medical Insurance Company
# of State Fines:    3
Total State Fines:    $1,820,610  (Source 1
ERISA Settlement: $9,975,000   (Source 6
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Continental Assurance
# of State Fines:    3
Total State Fines:   $161,212   (Source 1
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Coventry
# of State Fines:  1
Total State Fines:  $10,000  (Source 1
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CVS
ERISA Settlement: $3,000,000  (Source 6
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Dental Benefit Providers Maryland
# of State Fines:    2
Total State Fines:   $80,000  (Source 1
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Excellus
# of State Fines:    8
Total State Fines:   $36,400  (Source 1
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Florida 1st Health Plan
# of State Fines:    1
Total State Fines:  $25,000  (Source 1
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Fortis Insurance
# of State Fines:   3
Total State Fines:  $1,410,055  (Source 1
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Foundation Health
# of State Fines:    1
Total State Fines:  $50,000 (Source 1
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FreeState
# of State Fines:    1
Total State Fines:   $75,000 (Source 1
——————————————————————————————————————————————-
Great West Healthcare
# of State Fines:    4
Total State Fines:  $2,323,669  (Source 1
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Guardian Life
# of State Fines:    6
Total State Fines:  $1,440,305 (Source 1
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Hartford Casualty Insurance Company
# of State Fines:    1
Total State Fines:  $20,000  (Source 1
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Health Care Plan of NY
# of State Fines:    1
Total State Fines:   $20,500 (Source 1
——————————————————————————————————————————————-
Health Insurance Plan of NY
# of State Fines:    10
Total State Fines:  $351,350 (Source 1
——————————————————————————————————————————————-
Health Net
# of State Fines:    9
Total State Fines:  $521,700 (Source 1
ERISA Settlement: $215,000,000  (Source 6)
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Health Options
# of State Fines:    1
Total State Fines:  $50,000  (Source 1
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Healthplan Southeast
# of State Fines:    1
Total State Fines: $50,000   (Source 1
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HMO Colorado
# of State Fines:  1
Total State Fines:  $252,500  (Source 1
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Human Affairs
# of State Fines:    1
Total State Fines:  $5,500 (Source 1
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Humana (Publicly Traded)
# of State Fines:    9
Total State Fines:  $2,879,113 (Source 1
ERISA Settlement:  $58,000,000  (Source 8
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LifeGuard
# of State Fines:    1
Total State Fines:  $40,000 (Source 1
——————————————————————————————————————————————-
Magellan
# of State Fines:    2
Total State Fines:  $450,000 (Source 1
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Meco Health Solutions
ERISA Settlement: $42.5 million
——————————————————————————————————————————————-
Med Insurance Company of Ohio
# of State Fines:    1
Total State Fines:  $60,000 (Source 1
——————————————————————————————————————————————-
Mega Life and Health Insurance Company
# of State Fines:    3
Total State Fines:  $875,000  (Source 1
——————————————————————————————————————————————-
MetLife Insurance Company
# of State Fines:   5
Total State Fines: $1,343,428  (Source 1
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MDNY
# of State Fines:    9
Total State Fines:  $185,650  (Source 1
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Merit  Behavioral
# of State Fines:    1
Total State Fines:  $7,500  (Source 1
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Mid-South Insurance Company
# of State Fines:  1
Total State Fines:  $51,850 (Source 1
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Mid-West National Life
# of State Fines:    2
Total State Fines:  $140,500  (Source 1
——————————————————————————————————————————————-
New England Life
# of State Fines:    1
Total State Fines:  $41,500 (Source 1
——————————————————————————————————————————————-
New York Life Insurance
ERISA Settlement: $14,000,000  (Source 6)
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NYL Care
# of State Fines:   5
Total State Fines:  $1,092,050 (Source 1
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Oriska Insurance
# of State Fines:    1
Total State Fines:  $3,900 (Source 1
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Oxford Health Plans
# of State Fines:    13
Total State Fines:  $5,046,674 (Source 1
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Pacific Life and Annuity Company
# of State Fines:    3
Total State Fines: $3,530,579  (Source 1
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Physicians Healthcare Plans
# of State Fines:    2
Total State Fines:  $78,300 (Source 1
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Principal Life Insurance Company
# of State Fines:    2
Total State Fines:  $704,856 (Source 1
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Protective Life Insurance Company
# of State Fines:    2
Total State Fines:  $152,780 (Source 1
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Prudential
# of State Fines:    6
Total State Fines:  $216,000  (Source 1
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Qualmed Washington
# of State Fines:    1
Total State Fines:  $250,000 (Source 1
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Renaissance Health and Life
# of State Fines:   1
Total State Fines:  $1,750 (Source 1
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Rite Aid
ERISA Settlement: $67,600,000 (Source 6)
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Safeguard Health Plans
# of State Fines:    3
Total State Fines:  $239,339 (Source 1
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Sierra Health / Texas Health Choice Companies
# of State Fines:    3
Total State Fines:  $1,437,450 (Source 1
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Systemas Medicos
# of State Fines:    1
Total State Fines:  $7,500  (Source 1
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Trustmark Insurance Company
# of State Fines:    2
Total State Fines: $595,676  (Source 1
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United American Insurance Company of McKinney
# of State Fines:   1
Total State Fines:   $190,000 (Source 1
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United Healthcare
# of State Fines:    59
Total State Fines:  $50,514,675  (Source 1, 2, 3,4, 5
ERISA Settlement: $17,000,000 (Source 6
ERISA Settlement: $350,000,000 (Source 7
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Vista Health Plan
# of State Fines:    1
Total State Fines:  $50,000 (Source 1
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Well Care
# of State Fines:    6
Total State Fines:  $147,100 (Source 1
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 Sources:
2. http://americustimesrecorder.com/local/local_story_%20003234020.html
3. www.texmed.org/Template.aspx?id=6325
4. http://www.newsobserver%20.com/news/stor%20y/1152663.html
5. http://azstarnet.com/all-headlines/119565/
6. http://www.erisasettlements.com/press/ERISA-Chart.pdf

7. http://www.healthdatamanagement.com/news/ama-unitedhealth-insurance-lawsuit-ingenix-database-43997-1.html

8. http://www.bizjournals.com/milwaukee/stories/2005/10/17/daily14.html?from_rss=

U.S. Congress Working to Replace Physician Sustainable Growth Rate

May 17, 2012 Leave a comment

The U.S. Congress is currently working on legislation to replace the physician sustainable growth rate. Since 2002, this has become a highly debated topic in Congress that has resulted in 14 CRs (short-term measure) being passed that were aimed to delay a 30% cut to physician Medicare payments. H.R. 5707 introduced and aimed at replacing the SGR.

To get things started, The U.S. Senate Finance Committee held a roundtable discussion on the matter last week. You can view the discussion at http://www.finance.senate.gov/hearings/hearing/?id=ce954372-5056-a032-5269-10f65a59f5d4. In a statement, Chairman Max Baucus (D-MT) said : “Medicare’s sustainable growth rate (SGR) formula has not worked as planned. The annual cuts the formula calls for have snowballed the problem.” Ranking member Orrin Hatch (R-UT) said in a statement: “We must provide a stable foundation for paying physicians today, not five or 10 years from now.”

On May 9, a billed aimed at replacing the SGR was introduced. H.R. 5707: Medicare Physician Payment Innovation Act of 2012 was officially introduced in the House by members Allyson Schwartz (D-PA, former hospital CEO) and Dr. Joe Heck ,DO (R-NV, physician). The bill can be read here: http://www.gpo.gov/fdsys/pkg/BILLS-112hr5707ih/pdf/BILLS-112hr5707ih.pdf. In order for the bill to be successful, it will need to have FULL support by all of the physicians in Congress. The physicians that need to be encouraged to pass it are: John Barrasso (R-WY), Tom Coburn (R-OK), Rand Paul (R-KY), Dan Benishek (R-MI), John Boustany (R-LA), Paul Broun (R-GA), Michael Burgess (R-TX), Larry Buschon (R-IN), Bill Cassidy (R-LA), Scott DesJarlais (R-TN), John Fleming (R-LA), Phil Gingrey (R-GA), Paul Gosar (R-AZ), Andy Harris (R-MD), Nan Hayworth (R-NY), Ron Paul (R-TX), Tom Price (R-GA), Phil Roe (R-TN), Donna Christensen (D-VI), and Jim McDermott (D-WA).

Stay tuned to this blog for further updates on this story.

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Sources:

http://www.finance.senate.gov/hearings/hearing/?id=ce954372-5056-a032-5269-10f65a59f5d4

http://www.finance.senate.gov/imo/media/doc/05102012_Baucus_Roundtable_Statement_Regarding_the_Medicare_Physician_Payment_System%5b1%5d.pdf

http://www.finance.senate.gov/imo/media/doc/05%2010%2012%20Hatch%20Opening%20Statement%20for%20SGR%20Roundtable.pdf

http://www.gpo.gov/fdsys/pkg/BILLS-112hr5707ih/pdf/BILLS-112hr5707ih.pdf

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
—————————————————————————-
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
———————————————————————————
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
 ——————————————————————————————————————————————
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/

Physicians Say NO to Accountable Care Organizations

May 7, 2012 Leave a comment

Physicians in large numbers are rejecting Accountable Care Organizations (ACO). According to a survey by MedScape, physicians believe that these type of organizations are way to risky and are very vulnerable to being defrauded by insurance companies (evidence of insurance companies defrauding Medicare coming in next blog post). MedScape had 3,200 physicians respond to their survey and they came up with the following results:

5% of physicians want to be involved in an ACO

42% say physician alignment is impossible and is primary reason for not moving forward with ACO development

50% believe ACO federal guidelines will have a negative impact on patient care

52% say their income will be dramatically reduced

67% say they will not reduce the amounts of tests and procedures they order in order to comply with federal ACO guidelines

As you can see, there is a very large amount of physician resistance when it comes to ACOs.  In order for the ACOs and other alternative models to be successful, physicians MUST be in support of them. Otherwise, the concept will never work.

Sources:

http://www.medscape.com/viewarticle/761870_5

http://www.fiercehealthcare.com/story/physicians-say-no-thanks-risky-acos/2012-05-04

Community MedPac Groups Exempt from U.S. Health Insurance Mandate

March 13, 2012 Leave a comment

The Medical Access Corporation of America (MAC) is an organization that will be running CO-OPs across the nation. CO-OPs are exempt from the federal insurance mandate and are not allowed to be touched by the health insurance companies (which are indicted for fraud by U.S. DOJ). CO-OPs grant FULL access to all Americans and give 100% reimbursement to physicians. We are exempt from the federal insurance mandate.

Over 1,000 healthcare professionals in USA belong to our linkedin group Community MedPac. Consumers, health care policy makers, decision makers, health lobbyists, health system C-Suite executives (members of American College of Healthcare Executives), healthcare finance executives (members of Healthcare Financial Management Association), medical practice executives (CMPE), practice managers (members of the Medical Group Management Association), physician executives ( member of American College of Physician Executives), physicians (pediatrician, internist, family practitioner ob/gyn,etc), physician professional associations (American Academy of Pediatrics, American College of Physicians, American Academy of Family Practitioners, American College of Cardiology, American College of Obstetricians and Gynecologists, American Dental Association, Radiological Society of North America, etc) medical students, healthcare management students (HSA, MBA) ambulatory care, allied health, nurses, health IT professionals (HIMSS), physician recruiters, C-suite executive recruiters, and healthcare entrepreneurs are all welcome to join. You can join directly by going to: http://www.linkedin.com/groups?gid=2908799

Community MedPac has also formed many subgroups which will become the CO-OPs. Here is a listing of the subgroups:

Arizona                 http://www.linkedin.com/groups?about=&gid=4053619

California             http://www.linkedin.com/groups?about=&gid=4052220

DC/ VA/ MD      http://www.linkedin.com/groups?about=&gid=4049357
Florida                 http://www.linkedin.com/groups?gid=4052849

Georgia                http://www.linkedin.com/groups?about=&gid=4053637
Illinois                 http://www.linkedin.com/groups?about=&gid=4053632
Indiana                http://www.linkedin.com/groups?gid=4053641
Mass                     http://www.linkedin.com/groups?about=&gid=4053775
Michigan            http://www.linkedin.com/groups?about=&gid=4053644
Minnesota          http://www.linkedin.com/groups?gid=4053817
Missouri              http://www.linkedin.com/groups?gid=4053813
NY/NJ                  http://www.linkedin.com/groups?gid=4052203
 NC                         http://www.linkedin.com/groups?gid=4053808
Ohio                      http://www.linkedin.com/groups?gid=4052851
Penn                      http://www.linkedin.com/groups?gid=4053798
Tenn                      http://www.linkedin.com/groups?gid=4049274
Texas                     http://www.linkedin.com/groups?gid=4053630
Washington        http://www.linkedin.com/groups?gid=4053640
Please come be apart of improving and enhancing our healthcare system.

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

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