Once again we have “big” headlines here again about how hospitals and doctors bill Medicare. Sure there are absolute fraud cases and better use of analytics can certainly help identify patterns and bring those to light for investigation but overall that’s a small portion of the process. Again with HHS using their new software to identify patterns this should help with those cases. Now we get to the battle of the algorithms again with codes and what is actually being done at hospitals and doctor’s offices. You can read the entire article in it’s entirety and see some good points made. You do have to also remember there are the “consultants” that work with hospitals to show them areas to where they can increase revenue and save money. Many times too the consultants will quote some type of percentage figure with their sales pitch on how much additional revenue they are missing out on. This article misses the input there completely and whether or not they are right or wrong they exist and an entire industry exists because of this factor. I don’t know where the author got their information but he/she quoted that a medical records company is also touting higher reimbursement with using their system which is kind of unusual unless there’s a big focus on revenue cycling and that may be a separate module for purchase. I wrote about it back in October of 2011.
Bad Algorithms in Healthcare Payment Systems and Risk Assessments–Did the Hospital Bill Fraudulently or Were They Sold Formulas That Did Not Conform
You just have to be careful of when you read these OMG stories anymore about billing because most of the times there’s no good guy/bad guy here, just interpretations. One doctor says due to his medical records system he spends more time evaluating patient care and thus so does that deserve more money? You would have to be living under a rock not to realize the additional data that doctors review today compared to the past and they do spend more time and do a better job, but again the antiquate compensation systems sometimes look at these situations as upcoding, when in fact it may not be. In the news last year we had Prime for one example with one billing code and with automated coding how did this happen? Oh we go back to the queries and coders again, it is what it is when automated. Actually the companies that are set up to “just bill” that are fraudulent end up being better codes than doctors and hospitals as that’s their only focus as they don’t see patients and just work numbers.
Healthcare Billing Fraud–Office of the Inspector General HHS-OIG Is Finding “Organized Crime” With Some Criminals Armed With Guns and More….