It seems like the medical billing up-coding has finally caught up with the Federal Reserve. While I have been reading about fraud prevention controls along with audits from Medicare for some time now, I had no idea how much was at stake here. Kathleen Sebelius, the secretary of the U.S. Department of Health & Human Services (HHS) along with the Attorney General Eric Holder issued a warning that the law enforcement agencies will be more proactive in keeping an eye out for fraudulent activities. She addressed the healthcare associations in a letter promising action where warranted. “We will not tolerate fraud,” she wrote, explaining that the HHS takes their responsibility very seriously.
According to Medicare data, two of the highest codes were listed on nearly 40% of visitation claims from doctors in 2010, up from 25% in 2001. While some physicians suggested that an increase in average age has may have led to the increase in overall expenditure, research from the Center for Public Integrity shows that there has been no increase in the average age of the patients during that time frame. Most experts believe that this increase in medical billing is in part attributable to up-coding. Mark B. McClellan, who served as an Administrator for the CMS during 2004 to 2006, expects CMS to come down hard on medical billing fraud.
The Inspector General of HHS admitted that the medical billing coding system was vulnerable to fraud in a report released earlier this year. However he also stated that the extent of such problems cannot be determined precisely without examining each and every patient claim. According to federal estimates, over-charge from physicians can cost Medicare an average of $43, while a review can cost somewhere between $30 to $55. Farzad Mostashari, the National Coordinator for Health Information Technology responded that there was always going to be some level of fraud involved, and there always will be enforcement for it. When questioned if EHRs had allowed providers to fool the system, he explained that more work is being done and there is an increase in fraud identification along with the civil penalties and enforcement actions that exist. The new policies should be able to provide some cushion to the authorities, as the federal government looks to crackdown the root cause of the problem.
With the Rise of AI, What IP Disputes in Healthcare Are Likely to Emerge?
Munck Wilson Mandala Partner Greg Howison shared his perspective on some of the legal ramifications around AI, IP, connected devices and the data they generate, in response to emailed questions.
