Fraud Enforcement Cases Highlight the Importance of Accurate Documentation
It is common knowledge that a major focus of The Department of Health and Human Services (HHS) is to prevent and enforce current anti-fraud laws around the country. (www.hhs.gov/news/press (Jan. 24, 2011)). There are many programs that assist with this effort and include: the Health Care Fraud Prevention & Enforcement Action Team (HEAT), Recovery Audit Contracts (RACs), Zone Program Integrity Contractors (ZPICs) and qui tam or whistle blower law suits. The common thread is that they all rely on the documentation to substantiate their claims.
Last month, the Justice Department accused Kernan Hospital of fraud, “alleging in a civil complaint that it falsely labeled patients as kwashiorkor victims to inflate bills paid by government health programs and insurance companies.” (Jay Hancock, Malnutrition Diagnoses at Kernan Were Fraud, Feds Say, Baltimore Sun (Nov. 7, 2011). Kwashiorkor is common in Africa and other developing nations and is usually seen in children. Labeling “patients as simultaneously suffering from kwashiorkor or other malnutrition increased the amount Kernan was able to bill.” Ibid. While there are many instances where malnutrition may be appropriate, this was not one of them and there was nothing in the medical record to substantiate this condition.
In Houston, a physician was sentenced in Federal Court to 135 months in federal prison for “health care fraud conspiracy that federal officials charged resulted in false billings to Medicare and Texas Medicaid programs for $45,039,230 over a 2 ½ year period.” (SLP Health Care Risk Management & Operations Group News, Houston Doctor Gets 135 Month Health Care Fraud Sentence).
Likewise, in NY, a family-practice physician was indicted by a federal grand jury for allegedly submitting more than $13 million of false claims to Medicare. (John Carreyrou, Doctor Is Indicted in Medicare Case, Wall Street Journal (Nov. 5, 2011)).
In light of this recent activity, providers should assess their clinical documentation improvement and compliance programs. Reviewing documentation for accuracy, specificity and proper code assignment can assist in rebutting a claim for fraud.
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