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Healthcare provider pays for billing Medicare before services were fully performed. In U.S. ex rel. Montcrieff v. Peripheral Vascular Associates, 2023 WL 139319 (W.D. Tex. 2023), the court indicated it will award a minimum of $ 24 million in total damages, fines, penalties, and sanctions based upon a medical practice’s purported violation of the False Claims […]
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Illinois Physician Settles Case Involving False Claims
The settlement agreement resolves allegations that Dr. Tolitano submitted claims for Healthcare Common Procedure Coding System (HCPCS) code 93965, when those claims were for a procedure that was already included as a component of the duplex ultrasound procedures for which Dr. Tolitano submitted claims using HCPCS codes 93970 or 93971 for the same beneficiary on the same dates of service.
The post Illinois Physician Settles Case Involving False Claims appeared first on The Coding Network.
Texas Physician and Practice Settle Case Involving False Claims
The settlement agreement resolves allegations that Dr. Robbins submitted claims for Healthcare Common Procedure Coding System (HCPCS) code 93965, when those claims were for a procedure that was already included as a component of the duplex ultrasound procedures for which Dr. Robbins submitted claims using HCPCS codes 93970 or 93971 for the same beneficiary on the same dates of service.
The post Texas Physician and Practice Settle Case Involving False Claims appeared first on The Coding Network.
New Mexico Physician and Practice Settle Case Involving False Claims
The settlement agreement resolves allegations that Dr. Reddy submitted claims for Healthcare Common Procedure Coding System (HCPCS) code 93965, when those claims were for a procedure that was already included as a component of the duplex ultrasound procedures for which Dr. Reddy submitted claims using HCPCS codes 93970 or 93971 for the same beneficiary on the same dates of service.
The post New Mexico Physician and Practice Settle Case Involving False Claims appeared first on The Coding Network.
As if the coronavirus pandemic wasn’t bad enough as it is, fraudsters in the healthcare industry are manipulating it to further their wealth. The ongoing public health crisis has spawned a rash of fraudulent schemes, making COVID-19 fraud investigations a top priority for government agencies determined to root out fraud and corruption being committed against […]
The post Biotech Executive Charged in COVID-19 Test Fraud Case appeared first on AAPC Knowledge Center.
Ask the expert
Case managers trigger HIPAA concerns
Learning objective
At the completion of this educational activity, the learner will be able to:
Editor’s note: CMM received the following question from a case manager and reached out to our experts to provide their thoughts on how others might avoid this issue in the future.
Q: I am a certified case manager working in an acute care hospital. As part of our job requirements, when working in the emergency room (ER), we are asked to problem solve throughout the day. We often get requests for information on patients seen in the ER who have since been discharged.
These requests include phone calls and actual visits from the department of children and family services (DCF) looking for information on cases that were seen in the ER. Case managers were not actually present during these patient visits; however, information is needed to complete investigations related to DCF and others.
From time to time, we also receive phone calls from patients who have been discharged and are having trouble filling prescriptions given to them due to insurance coverage for that particular medication. They sometimes require a different medication to ensure coverage from their insurance plan.
Some case managers working on the acute care floors get phone calls from physicians and other case managers with a request to look at a case, as a consult, wanting to know if criteria have been met to advance an observation case to inpatient. Often, the patient in question is not on the case manager’s assigned floor for the day. We also access patient records, which are not on our assignment for the day, when we step in to help other case managers with heavy workloads when our own work is caught up.
If asked a month later why we accessed a particular record, we cannot always remember. It is not recorded anywhere, especially if we are just looking at a case for a second opinion for meeting criteria.
As a result, we’ve encountered a problem. Recently, an electronic medical record (EMR) audit was started on a nurse case manager accused of accessing a record when she did not need to view the information. This case manager is unable to remember why she accessed this record. She does not write down every request she encounters in a day.
This case manager has demonstrated admirable integrity, even self-reporting to the corporate compliance office when she faxed a prescription to the wrong pharmacy because she felt it was the right thing to do.
As case managers, we are given extended access to all medical records, including records for our psychiatric hospital that is separate from the hospital but on the same campus. Wouldn’t our roles as professionals extend a respect to us that we do not surf medical records for entertainment? If the case manager was found to be in an EMR, there was a professional reason.
Besides trying to document every request for accessing the EMR, what can we do for self-protection?
I would think that with the level of access to EMRs that we have been given to complete our job responsibilities, there should be a level of respect and protection on situations like this.
A: "It’s unfortunate that a case manager is under investigation for alleged indiscriminate access of electronic medical records," says Stefani Daniels, RN, MSNA, CMAC, ACM, president and managing partner of Phoenix Medical Management, Inc., in Pompano Beach, Florida.
"The nature of the role requires frequent access to protected health information (PHI), and neither a care manager nor utilization review specialist, or social service counselor should fear reprisal. It will simply put up barriers for future information sharing."
The cautious case management team must avoid delaying or obstructing care and should be doing more sharing than not enough, she says.
To allow this function to occur without fear of running afoul of regulations, a hospital should clearly spell out its policies and procedures as part of the case management program plan, EMR and HIPAA policies, and policies governing access to PHI, says Daniels. (A recent blog post might be of interest: www.phoenixmed.net/the-p-in-hipaa-does-not-stand-for-privacy.html.)
Jackie Birmingham, RN, BSN, MS, CMAC, vice president emerita of clinical leadership for Curaspan Health Group in Newton, Massachusetts, agrees.
"The professional responsibility concept can only be used if it is in the case manager’s job description with a policy to back it up," she says.
Case managers should not release information directly to DCF. Instead, it should go to the medical records/health information management (HIM) department so the hospital can ensure the request complies with its record release policies, that the appropriate forms are signed, and that the release is tracked, she says.
The case manager should always step back and think about every interaction he or she has with a patient or family, whether he or she is the primary case manager or just assisting with a case to help answer questions, says Cheri Bankston, RN, MSN, director of Clinical Advisory Services at Curaspan. "When you are asked a question and give direction to a patient/family member, then that should be documented in the patient’s medical record for reference by the healthcare team, such as your example of needing help getting a prescription filled," she says.
To protect the case manager and the organization, Daniels recommends that the hospital policy be clear on the following three topics:
1.Calls from outside agencies or other providers about discharged patients should be referred to the HIM department. If HIM needs clinical assistance, it will be able to identify and contact the case manager who was working on the case and make a referral directly to that associate. Case managers should never have to access records of discharged patients unknown to them.
2.Discharged patients should be able to contact their care manager directly. It’s good policy and is a value-added service of the case management program. Hospital policy should support this effort and outline a process to confirm the caller’s identity to protect PHI. Similarly, strategies for handling calls from physicians or other providers requesting PHI should be included in the hospital policy.
3.Members of the patient’s care team are always helping each other?that’s what teamwork is all about. Often, that help requires access to a patient’s EMR even if that team member is not providing direct care. Specifically, the policy should require a brief statement in the utilization review software, case management application, revenue cycle application, or paper chart. Detailed background information justifying access to the EMR should not be necessary; a brief, signed statement is sufficient: "At the request of (insert name of physician, case manager, etc.), PHI was reviewed for admission review (or continuing stay review, second opinion, quality audit, confirm physician order, or other reason)."
Consults from coworkers or physicians with questions about whether a patient meets criteria are activities that do not require documentation in the patient’s medical record as a general rule since this pertains to billing and insurance, says Bankston. "These activities may occur at any time during or after the patient’s stay," she says. "They are more problematic when auditing and many organizations take that into consideration when reviewing this during an audit of who has accessed a patient record. These activities are classified by roles such as utilization review, and each staff member that falls into that category would need to have a role that allowed them access to that record, similar to a coder in medical records."
Record reviews regarding payment and meeting criteria aren’t usually documented in the patient’s record because they pertain to payment, says Bankston. "In both cases, hospital compliance and legal counsel should have clear guidelines for staff. It’s not reasonable to document a note every time you review a record for medical necessity."
But unless a review falls into those categories, the bottom line is if you are answering questions from a patient or giving direction to a patient or family member, you should document those conversations in the EMR.
Got a question for our experts? Submit it to Kelly Bilodeau at [email protected].
I originally penned this blog post in 2011 and while the essence of DRGs hasn’t changed much, the coding system has. So here is the ICD-10 update to one of my most popular blog posts of all time. Enjoy!
So you want to be a coder. And not just that, you want to be a hospital coder because, on average, they make more money than physician coders. And you don’t just want to be a hospital coder, you want to be an inpatient hospital coder because then you get to look at the whole chart and piece together the patient’s clinical picture. If this is your goal, then everything you need to know you will not learn in school. And that’s mainly because there is so much to learn and practical experience is key.
Most of all, if you want to be an inpatient coder, you need to know diagnosis-related groups (DRGs) because in hospitals, it’s all about DRGs and case mix – and compliance. If you have no idea what I’m talking about, fear not – here’s a primer on DRGs! I wish I could say I cover it all here, but this is just a beginning!
What is a DRG?
The ICD-10-CM coding systems contains over 72,000 codes. Imagine trying to determine a payment amount for each individual condition. And that doesn’t include accounting for procedures (over 78,000 ICD-10-PCS codes). The most logical solution is to create a system that allows for broader classification of conditions and services for easier comparison and assignment into payment categories. DRGs were created for this purpose. I look at DRGs as a way to “organize the junk drawer” where patients are grouped into different categories based on similar conditions and cost to treat the patient.
History
DRGs were first developed at Yale University in 1975 for the purpose of grouping together patients with similar treatments and conditions for comparative studies. On October 1, 1983, DRGs were adopted by Medicare as a basis of payment for inpatient hospital services in order to attempt to control hospital costs. Since then, the original DRG system has been changed and advanced by various companies and agencies and represents a rather generic term. These days, we have various DRG systems in use – some proprietary and some a matter of public record – all of which group patients in different ways. Two of the main DRG systems currently in use are the Medicare Severity DRG (MS-DRGs) and 3M’s All Patient Refined DRGs (APR-DRGs). Different DRG systems are used by different payers.
How to Get a DRG
All DRG systems are a little different, but the basic premise is the same. DRGs are based on codes. In effect, DRGs are codes made up of codes. The following elements are taken into consideration when grouping a DRG:
Back in the 80s, DRGs were grouped manually using decision trees. These days, DRGs are grouped with the touch of a button and DRG groupers are a big part of encoding software. But I would be doing you a disservice if I didn’t at least give you an idea of the grouper logic. As I mentioned, there are different DRG systems and probably the most popular is the MS-DRG system, so I will explain how MS-DRG grouper logic works.
MS-DRG Grouper Logic
The first step in assigning an MS-DRG is to classify the case into one of the 25 major diagnostic categories (MDC). These MDCs are based on the principal (first) diagnosis and, with a few exceptions, are based on body systems, such as the female reproductive system. Five MDCs are not based on body systems (injuries, poison and toxic effect of drugs; burns; factors influencing health status (V codes); multiple significant trauma; and human immunodeficiency virus infection). Organ transplant cases are not assigned to MDCs, but are immediately classified based on procedure, rather than diagnosis. These are called pre-MDC DRGs.
Once a case has been assigned into an MDC (with the exception of the transplant pre-MDCs), it is determined to be either medical or surgical. Surgical cases require more resource consumption (that’s industry speak for “costs more!”), so they must be separated from the medical cases. If there are no procedure codes on the case (e.g., a patient with pneumonia may have no procedure codes), then it’s simple – it’s a medical case. But if the patient had a procedure, that procedure may or may not be considered surgical. For example, an appendectomy is quite clearly a surgical procedure. But something like suturing a laceration is not. It’s all based on resource consumption – the cost of performing the procedure. For the most part, anything requiring an operating room is surgical.
Okay, so now that we have our MDC and a designation as medical or surgical, we need to look at the other diagnoses on the claim. Right now, Medicare is able to process the first 18 diagnoses on the claim. These other diagnoses, depending on their severity, may be designated as complications and comorbidities (CCs) or major complications and comorbidities (MCCs). Medicare maintains lists of CCs and MCCs and updates them annually. CCs and MCCs are conditions that have been identified as significantly impacting hospital costs for treating patient with those conditions. For example, it’s been determined that congestive heart failure without further specification does not significantly impact costs and it is not a CC/MCC. However, patients with chronic systolic or diastolic heart failure do have slightly higher costs, so those conditions are CCs. More so, patients with acute systolic or diastolic heart failure have even higher costs, so they are designated as MCCs. Are you beginning to see how slight changes in a physician’s diagnostic statement impact coding and thus payment?
DRG Weights
Now that we know the MDC, whether the case is medical or surgical, and whether or not there are any CCs or MCCs, how does that translate into reimbursement? Well, if you’re using an encoder (and if you code for a hospital, you will), you hit a button and presto! You have a DRG with a relative weight. Now if only you knew what that relative weight meant. The DRG relative weight is the average amount of resources it takes to treat a patient in that DRG. Huh?
Let me demonstrate. The baseline relative weight is 1 and represents average resource consumption for all patients. Anything less than 1 uses less than average resources. Anything above 1 uses more than average resources. So let’s compare some respiratory MS-DRGs:
You can see how different combinations of codes lead to different MS-DRGs with different relative weights. In order to convert that into monetary terms, we multiply the relative weight by the hospital base rate. Now I’m sure you want to know how to get that hospital base rate. Me too. Well, up to a point. The base rate is exclusive to each hospital and takes a lot of historical, facility-specific data into account, like what they’ve been paid in the past, whether they are an urban or rural hospital, and how much the hospital pays out in wages. That’s just more math than my poor little head can comprehend! So for the purposes of this exercise, let’s pretend like this hospital – we’ll call it Happyville Hospital – has a base rate of $ 5000. So if we multiply the relative weights above by $ 5000, our reimbursement for those cases, respectively, is $ 53,932, $ 3,411, and $ 5,720.
Case Mix
You just might be asked in an interview if you understand case mix. It’s a good indication of whether someone really understands DRGs. And I have to admit, in my sometimes sadistic manner, I like seeing that look of glazed-over confusion on someone’s face when I bring up case mix. But case mix is simple. It’s the average relative weight for a hospital. So get out a big piece of paper for your hospital and start writing down the relative weights for every single case and then divide to get your average. Okay, so it’s computerized now. But that’s all case mix is – an average.
In the industry, we officially refer to case mix as the type of patients a hospital treats. Let’s say at Happyville, we have a high volume of transplant cases plus a trauma center and a well-renowned cardiac program. These are all highly weighted types of cases and our overall case mix will be higher than say, Anytown Hospital down the street that has no trauma center, no transplant program, and basic cardiac services (they transfer all their serious cardiac cases to Happyville!). Happyville’s case mix will be higher than Anytown’s.
As a coder, you don’t need to know what your specific hospital’s case mix is at any given time. But knowing what impacts case mix is an indication that you know your stuff. First and foremost, case mix fluctuates. Most hospitals monitor case mix on a monthly basis because changes in case mix are a precursor to changes in reimbursement. Of course your CFO wants case mix to continue to rise, but that could be a red flag. And he certainly doesn’t want case mix to fall. If case mix begins to decrease, the first place hospital administration usually looks is coding – after all, case mix is based on DRGs, which are based on codes. But there are lots of things that can impact case mix and many of them have nothing to do with coding, such as:
Your Life as an Inpatient Coder
As an inpatient coder your job is to make sure you get all the codes on the claim in the correct order so that the accurate DRG is assigned and the hospital gets paid appropriately. When I put it that way, it sounds so easy! The reality is, with more and more patients being treated as outpatients, those who are admitted as inpatients are sicker than they’ve ever been. And sicker means harder to code. For instance, the patient comes in with shortness of breath and the final diagnosis is acute exacerbation of COPD, staphylococcal pneumonia, and respiratory failure. How you code and sequence the case will determine the appropriate DRG and reimbursement. The good news is, you’ll have an encoder to help you model the DRGs and see what pays what. The bad news is, you have to paw through the medical record to determine the true underlying cause of that shortness of breath.
So are you ready for the challenge? Are you ready to apply DRGs?
Coder Coach
A Texas physician was found guilty Jan. 15 for his role in a $ 325 million healthcare fraud scheme that involved falsely diagnosing patients with various degenerative diseases and then administering chemotherapy and other toxic drugs to patients based on the false diagnoses, according to the Department of Justice.
After a 25-day trial, Jorge Zamora-Quezada, MD, was convicted of one count of conspiracy to commit healthcare fraud, seven counts of healthcare fraud and one count of conspiracy to obstruct justice.
Dr. Zamora-Quezada was charged in an indictment unsealed in May 2018. In addition to falsely diagnosing patients and administering unneeded drugs, he also allegedly conducted a battery of other fraudulent and excessive medical procedures on patients to increase revenue and fund his opulent lifestyle. Many patients, some as young as 13, suffered physical and emotional harm as a result of the false diagnoses and unnecessary procedures and chemotherapy injections, according to the Justice Department.
Read the full story on Becker’s Hospital Review here.
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Recently established coverage of the revolutionary cancer therapy Chimeric Antigen Receptor T-cell (CAR T-cell) provides Medicare patients with access to this cutting-edge treatment. The article Innovative CAR T-Cell Cancer Therapy Now Available to Medicare Beneficiaries breaks down Gilead Sciences’ Yescarta (axicabtagene ciloleucel) for acute lymphoblastic leukemia and Novartis’ Kymriah (tisagenlecleucel), approved for non-Hodgkin lymphoma and how this decision […]
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Former owner of a chain of skilled nursing and assisted living facilities in South Florida faces a 20-year sentence after being found guilty of a decades-long scam of paying bribes and receiving kickbacks in a massive billion-dollar Medicare fraud and money laundering scheme. This extensive healthcare fraud conspiracy resulted in hundreds of millions of dollars […]
The post Florida Exec Sentenced to 20 Years in $ 1 Billion Healthcare Fraud Case appeared first on AAPC Knowledge Center.