News: Baylor wins $61.8 million FCA case over alleged upcoding

In August 2018, Austin, Texas-based data analytics firm, Integra Med Analytics LLC, brought a qui tam (commonly known as a whistleblower) case against Providence Health & Services alleging that the organization had falsely billed for $188.1 million through upcoding various diagnoses, including severe malnutrition, encephalopathy, and respiratory failure. In early 2019, the case seemed to be on the road to dismissal.

Providence Health & Services wasn’t the only one under fire from Integra Med Analytics, however. The firm also filed a suit alleging that Baylor Scott & White, a large Texas-based health system, wrongly billed Medicare for more than $61.8 million over seven years through the practice of upcoding. Last week, U.S. District Judge David Ezra dismissed the case against Baylor, according to Modern Healthcare.

The initial complaint alleged that Baylor trained its physicians and CDI staff to encourage documentation of certain key words that would lead to MCC coding through targeted education, chart reviews, and tip sheets providing guidance on how to document diagnoses in a way that would be codable. Additionally, the complaint from Integra says that CDI professionals “pressured” physicians to change their diagnoses by sending them queries and asking them to specify their diagnoses when the initial documentation wouldn’t warrant a CC or an MCC. 

To substantiate their claims, Integra compared Baylor’s performance and instance of reporting certain MCCs against CMS inpatient claims data for short-term acute care hospitals from 2011 to 2017.

According to the dismissal, however, Judge Ezra said that educating physicians and CDI professionals to document in a way that allows accurate coding of CCs/MCC is “not in and of itself one to submit false claims and is equally consistent with a scheme to improve hospital revenue through accurate coding of patient diagnoses in a way that will be appropriately recognized and reimbursed by CMS commensurate with the type and account of services rendered.”

Additionally, the court said that the allegations did not prove that Baylor trained staff and physicians to document and diagnose patients in a way “that was not justified by the physicians own medical opinions, judgments, and the medical records.”

The data Integra provided, according to the court, could also simply show that Baylor was ahead of its peers when it came to accurately reporting certain MCCs as the gap between Baylor’s instance of reporting those conditions and other organizations’ reporting closed over the course of seven years.

“Plaintiff’s statistical analysis allegedly demonstrating that no other explanation but fraud accounts for the data it analyzed overlooks one major alternative hypothesis,” the dismissal says, “Defendants were simply better than their peers in their efforts to ensure their medical documentation and coding maximized the opportunities for legitimate reimbursement from CMS.”

Editor’s note: To read about the case against Providence Health & Services, click here. To read about other recent whistleblower cases, click here. To read Modern Healthcare’s coverage of this story, click here. To read the documents about the dismissal, create an account on pacer.gov.