Medicare Compliance & Reimbursement

Shoot for necessity and accuracy when billing for the services you render.

Upcoding sits atop the HHS Office of Inspector General’s hitlist. Sometimes upcoding occurs because of documentation errors or the EHR identifies the service under a higher-paying code. But in one North Carolina case, a provider knowingly upcoded to the tune of $6.5 million.

The Department of Justice’s (DOJ) qui tam case concerns a Charlotte-area organization, Carolina Healthcare System (CHS), which repeatedly billed urine drug tests under a higher-paying code from 2011 to 2015. The feds discovered that CHS was upcoding “by submitting claims using code G0431, which should be used only for tests classified as ‘high complexity’ by the FDA, instead of using code G0434,” the DOJ release said. “As a result of CHS’s upcoding practices, the government alleges that federal healthcare programs paid CHS, and certain facilities under contract with CHS, approximately $80 more per test for the claims submitted with the higher paying code.”

Result: The healthcare group agreed to shell out the $6.5 million tab in order to “resolve the allegations” with the feds.

“When healthcare companies try to boost their profits by billing federal healthcare programs for more expensive services than they actually provided, the Office of Inspector General will ensure they are held accountable for their deceptive schemes,” said Special Agent in Charge Derrick L. Jackson from the HHS-OIG Office of Investigations in the Atlanta Region.

Tip: Upcoding happens, but cases like these can be avoided with a comprehensive compliance plan. When a practice’s compliance program is based on doing things right, it maintains its effectiveness over the longterm.

Resource: To read the Department of Justice release, visit https://www.justice.gov/usao-wdnc/pr/carolina-healthcare-system-agreems-pay-65-million-settle-false-claims-act-allegations.