March 30, 2012

Baltimore Hospital to Pay Almost $800,000 in False Claims Settlement

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Good Samaritan Hospital in Baltimore will pay $793,548 to settle allegations that it erroneously added malnutrition to claims as a secondary diagnosis and received inflated reimbursement.

 


 

The hospital denied the charges, according to a March 28 announcement of the settlement from the U.S. Attorney's Office in Maryland.

 

The U.S. Attorney's Office alleged that the hospital had a system through which employees would use "leading questions so that the physician would answer that the patient was malnourished, which was the result [the hospital] wanted to achieve." Coders then used documentation of the false diagnosis to justify the malnutrition code, the U.S. Attorney's Office said.

 

"By falsely coding inpatients with a secondary diagnosis of malnutrition, [the hospital] caused its patient profile to appear worse than it was, thus increasing its reimbursement rate" from the Maryland Health Services Review Commission, the U.S. Attorney's Office stated.

 

The commission sets the rates used by all insurance companies for acute inpatient care in Maryland, including Medicare and Medicaid. As a result of the inflated rates, Good Samaritan Hospital received added reimbursement, the U.S. Attorney's Office stated.

 

2 Physicians Indicted

 

In other fraud news, two physicians with nine offices in Maryland and Virginia have been indicted on charges of conspiring to defraud the U.S. by hiding their true income and aiding in the preparation of false tax returns.

 

The doctors - a cardiologist and an internist - deposited more than $500,000 in checks from patients and insurance companies into a joint account instead of their practice's bank account, the U.S. Attorney's Office in Maryland stated in a March 28 press release. One of the doctors also opened other accounts in which he deposited payments for services rendered at the medical practice.

 

The doctors concealed the accounts from the accounting firm, the U.S. Attorney's Office said.

 

RACs Post Inpatient, Outpatient Issues

 

Region B recovery auditor (RAC) CGI posted two inpatient hospital issues while region C RAC Connolly posted two outpatient issues. For more information, see the chart below.

 

Inpatient hospitals

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Female reconstructive procedures (MS-DRG 748)

3/19/12

RAC Region B

The purpose of this complex review is to identify claims that have been reviewed validating medical necessity in short stay, uncomplicated admissions. This review will identify if medical necessity was met per Medicare guidelines.

Medicare Benefit Policy Manual chapters 1, 6, 10; Medicare Claims Processing Manual chapter 4; Medicare Program Integrity Manual chapters 6, 13; OIG reports A-03-00-00007, OAI-05-88-00730, A-01-10-01000; 2009 Report to Congress on the Evaluation of the Quality Improvement Organization Program for Medicare Beneficiaries for FY 2006; Pepper report; WPS LCD DL32222; Highmark LCD L27548; Section 1886(d) of the Social Security Act


 

Inpatient Hospitals

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Minor back/neck procedures (MS-DRGs 028, 029, 030, 040, 041, 042, 490, 491)

3/19/12

RAC Region B

The purpose of this complex review is to identify claims that have been reviewed validating medical necessity in short stay, uncomplicated admissions. This review will identify if medical necessity was met per Medicare guidelines.

Medicare Benefit Policy Manual chapters 1, 6, 10; Medicare Claims Processing Manual chapter 4; Medicare Program Integrity Manual chapters 6, 13; OIG reports A-03-00-00007, OAI-05-88-00730, A-01-10-01000; 2009 Report to Congress on the Evaluation of the Quality Improvement Organization Program for Medicare Beneficiaries for FY 2006; Pepper report; WPS LCD DL32222; Highmark LCD L27548; Section 1886(d) of the Social Security Act

 

Outpatient hospitals

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Colony stimulating factors - outpatient

3/23/12

RAC Region C

LCD policy has indicated specific conditions or diagnoses that are covered for Colony Stimulating Factor injections. These outpatient claims have been identified where the first-listed and/or other diagnosis codes do not match to the covered diagnosis codes in the LCD policies.

TrailBlazer LCD 26768; Palmetto LCD L31574; WPS LCD L30306; Pinnacle LCD L31018; Pinnacle LCD L19896; Cahaba LCD L30026; First Coast Service Options LCD L28878; First Coast Service Options LCD L28845

Hospice-related services - outpatient

3/23/12

RAC Region C

Services related to a hospice terminal diagnosis provided during a hospice period are included in the hospice payment and are not paid separately.

Medicare Claims Processing Manual chapter 11; Medicare Benefit Policy Manual chapter 9

 

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

 

Contact the Author

 

KLong@decisionhealth.com

 

To comment on this article please go to editor@racmonitor.com

 

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