Kaiser joins the undignified ranks of the companies investigated for committing fraud. This timely article from Healthcare Finance News doesn’t use that word, but it describes the finding that Kaiser “knowingly submitted” false diagnoses to inflate its payments, which is the definition of fraud. It’s certainly a sad day for a healthcare giant to be guilty of this conduct but it’s not surprising.
Since our company started working in risk adjusted reimbursement in 2004, and more so today, we have seen the upcoding that regularly occurs for medical conditions. Our chart reviews never fail to find conditions that have been mis-coded as risk-adjusted when the proper code is not weighted. Sometimes it happens through ignorance of the guidelines, but many times, we encounter provider groups where clinicians defend their actions as appropriate.
One true example occurred to us this year when a cardiologist who was versed in risk adjustment told us that if he codes ischemic cardiomyopathy, there will be no risk adjusted payment because this condition is not weighted. But he “knows” how sick the patient is so he codes cardiomyopathy, unspecified which does risk adjust. It is improper and fraudulent for a provider to know for a fact that a patient has one condition and mis-characterize it as another for payment purposes.
We can’t stress enough to every client, consider a compliance audit. Hire someone external to your organization to objectively review a sample of your providers’ charts and validate the codes you’re submitting to Medicare Advantage plans. If you’re concerned about what they’ll find, consider that you have the opportunity to remediate improper coding behavior and show a government regulator your intent to run a lawful organization. Not knowing and not even being curious to know will be no defense during a payment audit.