A case from America illustrates the serious consequences of upcoding.
John Peter Smith Hospital in Tarrant County, Texas, has agreed to pay $3.3 million in order to settle allegations that it was in violation of the False Claims Act by upcoding certain claims. The settlement is to resolve a whistleblower case filed in 2018 by the hospital’s former director of compliance. The former director’s complaint asserted that the hospitals improperly appended billing modifiers to hundreds of claims in order to receive higher payments.
The billing modifiers are intended to indicate that a provider administered significant care that was beyond preoperative and postoperative care on the same day as another medical procedure. The former director of compliance alleged that she alerted hospital leadership that these modifiers had been improperly added between 70% and 95% of the time. This essentially routinely doubled billing for certain aspects of patient care.
Because John Peter Smith Hospital neglected to reimburse payers for overpayments from the improperly coded claims regardless of the former director’s guidance, the hospital will pay the $3.3 million for the settlement.
This article originally appeared in the ACDIS journal CDI Strategies and has been republished with permission.
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