[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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