ED Coding and Reimbursement Alert

Question: We recently had a meeting with hospital administrators where they said we’re admitting an inordinate number of patients to inpatient status and they want to review our records. Why is this an issue?

Minnesota Subscriber

Answer: Some EDs have been suspected of admitting patients to the hospital without medically necessary reasons in a bid to increase overall hospital billings.

In its latest Semiannual Report to Congress, which covers HHS Office of Inspector General (OIG) activity for the reporting period that runs from Oct. 1, 2018 to March 31, 2019, the federal watchdog expects to recover $496 million from audits and $2.30 billion from investigations.

The OIG’s Semiannual Report offers advice, insight, and cost-saving measures to HHS on ways to improve the various federal healthcare programs that fall under its umbrella, like CMS. However, a big chunk of the brief focuses on fraudsters who attempt to bunk Medicare and Medicaid — and admissions from the ED are among the items listed in the report.

According to the OIG’s report, Tennessee’s Health Management Associates, Inc. (HMA) subsidiary, Carlisle HMA, LLC (Carlisle), conspired to defraud Medicare by increasing emergency department (ED) admissions in its hospitals and billing for “higher-paying inpatient care.”. Providers were pressured by HMA, even when ED admissions weren’t medically necessary. The settlement of the case is complicated as HMA entered into a Non-Prosecution Agreement (NPA) with the feds and will pay $35 million in civil monetary penalties (CMPs) plus an additional $2.5 million criminal fine. Plus, the HMA fraud includes eight False Claims Act (FCA) cases with another civil resolution equaling $261 million to resolve violations.

Even if you do admit a higher-than-average number of patients from the ED into inpatient status, that doesn’t mean you’re committing fraud. However, it’s a good idea to perform occasional self-audits to ensure that your hospital admissions are warranted and medically necessary.

Resource: Read the Semiannual Report to Congress at https://oig.hhs.gov/reports-and-publications/archives/semiannual/2019/2019-spring-sar.pdf.