Best Advice Ever: Make 2025 Your Most Ethical Year

Well, if ever there was a time of great uncertainty in healthcare, it is right now. The new administration will bring new leadership with new priorities. There is lots of talk, but I will wait until there is action to pass judgement.

On the positive side, the out-of-pocket maximum for Part D drugs is now $2,000, down from $8,000. With the increasing costs of medications and many new medications being introduced costing hundreds of dollars a month, that new limit will be literally lifesaving for many seniors.

Of course, on the negative side, there is no sign that the number of fraudsters out there will decline. Granted, the reports from the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) and Department of Justice (DOJ) are of fraud that occurred in past years, but 2024 saw many reports that were eye-opening.

To no one’s surprise, almost every audit of diagnosis codes submitted by Medicare Advantage plans to boost their Risk Adjustment Factor (RAF) scores saw a significant number of those codes that were not supported by the documentation in the medical record. On the plus side, these audits are finally looking at 2018 submissions, which means that the OIG can finally extrapolate the results and assess meaningful multi-million-dollar payback demands, rather than the pocket-change demands for audits prior to 2018.

But the reports that I found most distressing involved the number of providers who were found to be flaunting the regulations for financial gains. And in one recent case, a hospital used more than one fraudulent process for financial gain. Nina Youngstrom covered this story in her Report on Medicare Compliance, but let me share some details.

First, the hospital used their clinical documentation program to get doctors to document conditions that were not clinically supported in order to capture more Complications and Comorbidities (CCs) and major CCs (MCCs).

Then, and probably most offensive to me, was their scheme to get more inpatient admissions. That was a multi-pronged plan. First, they financially rewarded doctors to admit more patients as inpatients, with ED doctors getting $120 per admission and hospitalists getting $130 per admission. Then, they had their charge nurses unilaterally place verbal inpatient admission orders without any discussion with the physician, including placing an inpatient order for patients who were still in the ED waiting room, having yet to be seen by a provider, so the inpatient admission started prior to midnight.

The documentation scheme was discovered by what I will call a “serial whistleblower,” an experienced clinical documentation integrity (CDI) nurse who used Medicare claims data to analyze the hospital’s pattern of DRGs with CCs and MCCs and the number of one-day inpatient admissions. The short-stay data was really interesting: they found that 44 percent of the one-day inpatient admissions were billed with an MCC. Now, we don’t know if any of these patients started as observation and then were admitted as inpatients, but still, that number is high.

It’s only data, and data is not the same as a chart review to check the veracity of the claims, but the whistleblower is $1.8 million richer. And this follows her $6 million payday for another whistleblower case she settled in 2018.

The latter scheme was brought to light due to a physician assistant who briefly worked at the hospital and found the practices unacceptable. We don’t know his share of the settlement, but I bet he can take a nice vacation.

And last week, the Department of Justice indicted Chesapeake Regional Medical Center for allegedly allowing a gynecologist for years to do unnecessary surgeries on patients, including sterilization and hysterectomies. The doctor is already in prison; we will now see what happens to the hospital executives. The press release notes that this physician was recredentialed year after year, despite a previous felony conviction, multiple medical malpractice lawsuits, and a warning from another hospital that they suspended the physician for performing unnecessary surgeries. This is especially worrisome as credentialing is a medical staff obligation, suggesting that some medical staff members may have been involved.

My message for all of you: for 2025, be the most ethical person you can be. If you see something, say something. Follow your compliance department guidelines for reporting. Every Medicare-participating provider must have a compliance plan that includes a method to report concerns without worrying about retribution. No argument about the unfairness of the system or the abuses by the other side justify you participating in any improper activity. And maybe it was not intentional, but an oversight or misinterpretation of always complex regulations. But if you have to become a millionaire to effect change, so be it. I am sure famed whistleblower attorney Mary Inman, a frequent guest on Monitor Mondays, would be happy to talk to you.

Programming note: Listen to Dr. Ronald Hirsch make his Monday rounds on Monitor Mondays with Chuck Buck at 10 Eastern and sponsored by R1-RCM.