News: Whistleblower case highlights leading query concerns

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 the U.S. Department of Health and Human Services (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).

 

"The case is very much to the credit of these coders who felt so strongly about their ethical obligations. They insisted that they wouldn't add the codes that the doctor was directing through the query process," says Jamie M. Bennett, Esq., then assistant U.S. attorney for the District of Maryland. "They're really courageous people."

 

Isolated honest mistakes won't trigger an investigation, but ongoing patterns of fraud and abuse may, says Bennett, who presented during a 2011 ACDIS National Conference general session (ACDIS members have access to the PowerPoint presentation in the ACDIS Forms & Tools Library).

 

In the Bayview case, investigators identified patterns of queries designed specifically to ferret out ­opportunities for increased reimbursement a situation which highlights the problem of leading queries. The physician also sent e-mails to treating physicians that included the answers to queries initiated on paper. These e-mails often included the financial impact of the ­response, says Bennett.

 

Editor’s Note: This article was originally published in the August issue of Briefings on Coding Compliance Strategies.