Part B News quotes Kaiser on Possible DOJ Action Over Healthcare Upcoding Issues

February 28, 2023 | Compliance Investigations & White Collar

Geoffrey Kaiser was quoted in the Part B News article, “Be careful about upcoding; DOJ may come after it as a false claim.

A recent Department of Justice settlement in North Carolina has people wondering, how frequently the DOJ gets involved in healthcare upcoding cases. While reviewing recent cases, one can see that DOJ action is not triggered by only upcoding issues, in fact, it only seems to be one part of the equation.

Jeff comments, “It is not the case that the government does not prosecute, civilly or criminally, this type of misconduct unless it is included with other kinds of billing fraud.” Jeff points to the Prime Healthcare Services (PHS) ex-relator case that was settled in 2018 after seven years of legal wrangling. The original 2011 complaint alleged that PHS “explicitly instructed its physicians and hospital staff to disregard Medicare guidelines and to choose inpatient admission over outpatient/observation status in almost every instance, regardless of whether the criteria for inpatient admission has been satisfied.” In 2018, DOJ settled for $65 million and referred to the allegations as including “a practice known as ‘up-coding.'”

“Sometimes, a provider will upcode a diagnosis code to justify billing for a particular medical service or to obtain higher reimbursement under the Medicare Advantage Program for an allegedly ‘sicker’ patient population,” Jeff says. “And sometimes, a provider will intentionally misdescribe the service performed so that it will be paid by insurance — e.g., performing a ‘nose job’ (rhinoplasty) but billing for a deviated-septum repair. All of these forms of misconduct have been prosecuted at one time or another and, depending on loss amount and other factors such as any public health risk that may exist, the government does not require any additional justification — such as additional billing misconduct — to move forward.”

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