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Recent FCA activity focuses on coding compliance issues

Recently in healthcare news were articles about two legal actions that cause one to reflect on the need for a strong (or stronger) coding and clinical documentation improvement (CDI) compliance programs. 

The first legal action cited the False Claims Act (FCA) and possible “upcoding” at Providence Health and Services, headquartered in Renton, Wash. The lawsuit was filed by Integra Med Analytics, which claims that Providence, with the help of an outside consultant, pushed physicians to add secondary diagnoses when documenting treatment so the health system could qualify for higher Medicare reimbursement. The outside consultant, a clinical documentation improvement company, is J.A. Thomas and Associates. Providence operates 34 hospitals across five states. According to the suit, about $6.2 billion of Providence’s $14.4 billion in revenue in 2015 came from Medicare reimbursement.

The specific claim against Providence is seeking $188.1 million related to alleged Medicare upcoding. We will need to watch the progress and outcome of this suit.

The second FCA case targets Prime Healthcare Services, headquartered in Ontario, Calif., which recently settled with the U.S. Department of Justice for $65 million.  The settlement indicates that Prime was involved in submitting false claims to Medicare by admitting patients who required only less costly outpatient care, and by billing for more expensive patient diagnoses than the patients had or “upcoding.” Prime Healthcare operates 45 acute-care hospitals in 14 states.

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has given ongoing guidance regarding the prevention of fraud, waste, and abuse. The core and foundational series of documents from the OIG that help guide the healthcare industry were published from 1998-2008; the documents are directed at various segments of the healthcare industry, such as hospitals, nursing homes, physician practices, ambulance suppliers, Medicare+Choice organizations, third-party billers, and durable medical equipment suppliers, to encourage the development and use of internal controls to monitor adherence to applicable statutes, regulations, and program requirements.

The OIG has stated that the following elements should at a minimum be a part of a hospital compliance program:

  1. The development and distribution of written standards of conduct, as well as written policies and procedures that promote the hospital’s commitment to compliance (e.g., by including adherence to compliance as an element in evaluating managers and employees) and that address specific areas of potential fraud, such as claims development and submission processes, code gaming, and financial relationships with physicians and other healthcare professionals;
  2. The designation of a chief compliance officer and other appropriate bodies, e.g., a corporate compliance committee, charged with the responsibility of operating and monitoring the compliance program, and who report directly to the CEO and the governing body;
  3. The development and implementation of regular, effective education and training programs for all affected employees;
  4. The maintenance of a process, such as a hotline, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation;
  5. The development of a system to respond to allegations of improper/illegal activities and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, regulations, or federal healthcare program requirements;
  6. The use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas; and
  7. The investigation and remediation of identified systemic problems and the development of policies addressing the non-employment or retention of sanctioned individuals.

For those of us who work in or with documentation, clinical coding, and coded data, we should be taking these key elements and embracing them, molding them into a specific compliance program and/or plan that covers and addresses clinical coding and clinical documentation improvement functions and activities.

Even if you have such a coding compliance program in place today, now is the time to rethink your program, considering the recent legal action mentioned above. Even if you have education and training being provided, conduct an assessment of its success and results, and determine if attendees and staff are really learning and retaining the expected knowledge. Even if you have auditing and monitoring in place, conduct an assessment on the processes and results. Check into if there is any manipulation of audit targets, audit results, and/or planned and/or recommended corrective action.

If you have written policies and procedures, review them, determine if they are accurate, and ask whether they follow coding guidelines and ethical standards. Check if they are up to date and whether they are being adhered to. If you don’t have written policies and procedures, ask why, and begin to develop them. Interview staff and conduct a coding compliance survey to get feedback and input regarding the culture that your practice, department, organization, or company has. 

Watch and question setting metrics or goals that are primarily financially centered for coding and CDI. Also, do not allow your coding and CDI efforts to only be dedicated to one payor (Medicare), and make sure that your physician querying work has a quality assurance and validation process in place that follows industry best practices (i.e., American Health Information Management Association, or AHIMA, practice briefs).

We need to be stronger and bolder, exhibiting the leadership needed to have an effective and successful coding and/or CDI compliance program. With greater and greater financial pressures across healthcare, the risks and vulnerabilities increase.

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Gloryanne Bryant, RHIA, CDIP, CCS, CCDS

Gloryanne is an HIM coding professional and leader with more than 40 years of experience. She has an RHIA, CDIP, CCS, and a CCDS. For the past six years she has been a regular speaker and contributing author for ICD10monitor and Talk Ten Tuesdays. She has conducted numerous educational programs on ICD-10-CM/PCS and CPT coding and continues to do so. Ms. Bryant continues to advocate for compliant clinical documentation and data quality. She is passionate about helping healthcare have accurate and reliable coded data.

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