[Solved] 6-1 Discussion: Upcoding a Patients Bill
Hello Everyone,
Baylor operates
a network consisting of around twenty inpatient short-term acute care hospitals
in Texas. Medicare covers a significant number of patients served by
Baylor. Thus, Baylor regularly submits
reimbursement claims to Medicare, and Medicare reimburses it on a per-charge
basis. In 2019, Baylor
won an upcoding lawsuit filed in 2017 by a whistle-blower that claimed it
wrongly billed Medicare for more than $61.8 million over seven years (Luthi,
2019). According to Luthi (2019), the whistle-blower claimed that Baylor, led
by its clinical documentation improvement (CDI) program, used higher value
Compilations or comorbidities (CCs) and major compilations or comorbidities
(MCCs) than were justified by actual medical diagnoses to increase its revenues.
Ideally, the whistle-blower claimed that Baylor trained its physicians and CDI
employees to upcode MCCs by focusing on Keywords, emphasizing that they use
specific terms to increase their performance pay. The whistle-blower also
claimed that Baylor pressured physicians to alter their original diagnosis by
providing documents and asking them to change or specify the diagnosis if they
did not include MCCs and CCs. It further claimed that the care provider offered
unnecessary treatment to code high-value MCCs.
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