Professional and facility coding represent different aspects of a healthcare visit. Hence, the longstanding tradition has been that many hospitals and health systems tend to keep the departments separate. For a growing West Coast-based health system, keeping a wall up between professional and facility coders meant double the work as the volume of claims increased.
According to the AMA’s Principles of CPT® Coding, ninth edition, as reported in the AMA Wire® newsletter, when it comes to medical coding errors, they fall into the broad categories of “fraud” and “abuse.” The former involves intentional misrepresentation. The latter means “the falsification was an innocent mistake, but nonetheless representative,” An example of abuse could involve coding “for a more complex service than was performed due to a misunderstanding of the coding system.”
A recent article in Medical Economics pointed out a persistent problem that some physicians continue to overcode and overbill, despite increased focus on the cost of healthcare and scrutiny by federal regulators. According to the article, a new report by ProPublica, which analyzed CMS data between 2012 to 2015, a number of physicians overcoded on services provided under Medicare’s Part B program.
Aviacode joins American Health Information Association (AHIMA) in celebrating health information professionals during the 29th annual Health Information Professionals (HIP) this week (March 18–24, 2018).
A recent Becker’s Hospital Review article stated that Catholic Health had agreed to pay $6M to settle overbilling allegations. A nursing home subsidiary of the health system allegedly submitted claims to Medicare for the highest and most expensive levels of therapy when that type of therapy was not medically necessary or was unsupported by medical records. The allegations against Catholic Health were originally brought by a whistle-blower under the qui tam provision of the False Claims Act.
The medical sector has been undergoing a series of interminable changes over the last few years. In consequence, healthcare revenue cycle management (RCM) market is set to witness a marked growth because of the rising need for timely bill reimbursements and insurance claims. Increased complexity in the medical coding process has led to the necessity of RCM solutions that help reduce billing errors.
Almost three-quarters of struggling hospitals are re-prioritizing revenue cycle management over a number of other initiatives. A recent Black Book Market Research survey uncovered that hospitals leaders are pushing revenue cycle management to the top of their priority lists in this last quarter of 2017. The Black Book Research indicated that 74 percent of struggling hospitals are putting population health, analytics, physician practice acquisitions and recruitment, and patient engagement on the back burner to reprioritize revenue cycle management through Q4 2017.
A recent nationwide ICD-10 coding accuracy and productivity contest by Central Learning demonstrates the fact that the medical coding industry still needs to greatly improve in order to achieve a respectable and acceptable ICD-10 and CPT coding accuracy level. Although there was a slight improvement in inpatient and emergency department accuracy, the ambulatory surgery accuracy score decreased. The average inpatient coder accuracy was 61 percent and the average outpatient coder accuracy was 41 percent.
As you are well aware, Congress created Medicare Advantage (MA) as a risk adjustment payment program that pays insurers more for sicker beneficiaries. Payers in MA receive a yearly fee for each enrolled member and monthly risk adjustment payments for each enrolled beneficiary, based partly on the person’s health status. This program can be open to fraud. Medicare Advantage payers received about $160 billion in 2015 for approximately 16 million beneficiaries. HHS estimates that the FY 2015 Medicare Part C gross improper payment estimate is 9.50 percent or $14.12 billion, along with the FY 2015 net improper payment estimate of 4.32 percent or $6.41 billion.
An article in Modern Healthcare magazine reported that physicians who serve low-income patients with complex conditions are more vulnerable to financial losses in value-based payment models. The study that found these providers, many of them safety-net providers, didn't have the technological infrastructure to report the necessary data.