Note from the ACDIS Director: The real face of fraud—it’s not CDI

By Brian Murphy

In the stream of e-newsletters that flood my inbox each day I occasionally see reports that give me momentary pause about the CDI profession.

For instance, a Medicare Compliance Review of Rush University Medical Center recommends that the hospital refund $10.2 million to Medicare. Part of this amount is from a review of inpatient claims billed with high-severity-level DRG codes that “did not fully comply with Medicare billing requirements.”

The Recovery Audit Contractor (RAC) program could, according to the Weekly Standard, cut the deficit by $534 billion in “cost savings in programs where the taxpayer is getting ripped off.”

Then along comes a report like this December 6 article from the Wall Street Journal: “Brooklyn Prosecutors Charge 20 in $146 Million Health-Care Fraud.” This article describes a case where the defendants (allegedly) paid patients to come to clinics to receive unnecessary tests—tests the defendants billed to Medicare and Medicaid. The money was then laundered through bank accounts in shell companies in Taiwan and Lithuania. You can read the full account of this sordid behavior here.

Forget about RACs and compliance reviews by the OIG. This is the real face of fraud.

Fraud is not querying for a diagnosis based on definitive evidence of a more severe condition. It is not having a clinical conversation with a physician to clarify whether the patient’s post-operative ventilator status is expected due to the nature of the procedure. And it’s certainly not to be found in the daily battles hospitals and RAC auditors wage about whether a patient with multiple chronic conditions should have been admitted or could have been placed in observation.

Upon closer inspection, many of these findings are in fact the subjective criteria of a single medical reviewer, sometimes a physician or clinician, sometimes not. Sometimes with a coding credential, and sometimes without.

I’m not a Pollyanna or saying there aren’t unethical practices that occur in the CDI profession. There are. But these are the exception. Nor am I saying that auditors should not exist and don’t have a role to play in protecting the Medicare Trust Fund—they should. Human error happens.

But what I can also confidently say is that 99% of our ACDIS membership believe in what they do, act ethically, and just want to do the best job they can. They work in a system that pays based on how severely ill the patient is—severity that is represented by what the physician documents. If a hospital is today without a CDI department, it’s not operating with all the pieces CMS itself has put in place in this complex game of healthcare quality and reimbursement and accurate depiction of patient severity of illness.

So keep doing the good work you do, in a fearless manner. Use evidence-based clinical practice to formulate your questions to the physician. Allow him or her the room to exercise clinical judgment, and or/admit they don’t know the answer. Follow the recommendations developed in Guidelines for Achieving a Compliant Query Practice.

And if your CDI work is scrutinized or denied by an auditor, know that these denials are often highly subjective in nature, as is common in the intersection of coding with clinical and the business of medicine with the delivery of medicine.

Flip denials on their head: Use them as learning opportunities for yourself and your providers to build a more defendable record in the future, one that tells a short, but accurate, story of medical necessity.

Never feel guilty about the work you do in this honorable profession. It’s too important—and it’s the right thing to do. As the Wall Street Journal article demonstrates, real healthcare fraud is out there—not in the compliant practice of CDI.

Editor’s note: Murphy is the director of ACDIS. Contact him at bmurphy@acdis.org. To read more about the denials landscape and tactics for fighting and preventing denials, read the September/October edition of CDI Journal.