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Medical Coding Complications and Greed

[By Darrell K. Pruitt DDS]

Coding complications in government healthcare ALWAYS favor the house — CMS guarantees it with lawsuits and whistleblower rewards that could attract dishonest employees. Are you careful who you hire?

Complications 

Complications in healthcare informatics – including 5-digit CPT® code mistakes as well as foul-ups that involve physicians’ “voluntary” 10-digit National Provider Identifier numbers – ALWAYS grant insurers more time to pay past-due bills owed to their clients and their clients’ doctors.

Call me Cynical 

Call me cynical, but if interest rates climb ever higher as predicted, watch for unexplained, proportional increases in coding errors to help fund insurance CFOs’ bonuses while raising the cost of healthcare even more without improving value. Is it any wonder why Americans don’t get the quality of healthcare we purchase compared to citizens in other countries? Tax-payers in my neighborhood are begging for in-network providers who put their patients’ interests ahead of insurers’ as much as allowed by insurers’ self-serving rules – without committing fraud. As a general rule, healthcare stakeholders accommodate parasites more than principals.

CPT® Codes and Patient Care 

Accurate CPT® coding may have nothing to do with patient care, but CMS makes it nevertheless important to physicians. Whereas the most innocent NPI foul-ups reliably delay payment and never turn out well for providers, the new fraud and abuse provisions of the Patient Protection and Affordable Care Act [ACA] can cause an innocent coding mistake on a Medicare claim to land the doc in court with charges of fraud depending on the quality of employees one hires – but only if the error favors the provider and not the payer. In June, David Burda posted “Attorney tells audience to brace for a storm of whistle-blower lawsuits” on ModernHealthcare.com.

http://www.modernhealthcare.com/article/20100623/NEWS/306209989/-1

Of Whistle-Blower Lawsuits

Burda reports that healthcare attorney Joanne Judge, a partner with Stevens & Lee in Reading, Pa., predicts a significant increase in whistle-blower lawsuits simply because the new law makes it far too easy for a dishonest employee to file an unwarranted lawsuit. No longer is there a requirement for the whistleblower, who stands to win money from his or her patriotic effort, to directly witness the crime. That kind of idea could catch on in this economy.

“The new law also converts accidental Medicare overpayments to providers into potential false claims, Judge said. She said the law considers an overpayment as fraud if the overpayment isn’t identified by the provider and returned to the government within 60 days. Judge said that will require providers to beef up their internal billing systems to detect an overpayment as soon as possible and then send Medicare back its money.”

Assessment 

What can possibly go wrong with that plan? Thorough background checks on all new employees is increasingly important, doc. For my employment security issues, I’ve learned to depend on Richard at Investigation Resource Service out of Dallas. He’s never let me down (This is not a paid ad).

• http://www.pi-spy4u.com/

Conclusion

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Filed under: Information Technology, Managed Care, Practice Management | Tagged: ACA, ARRA, CMS, CPT, CPT codes, Darrell K. Pruitt DDS, David Burda, Health Informatics, HIT, HITECH, Joanne Judge, medical coding, Modern Healthcare, National Provider Identifier, NPI, Patient Protection and Affordable Care Act, Stevens & Lee | 3 Comments »