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$188 Million Medicare Fraud Allegations Filed Against Health System and Clinical Documentation Improvement Vendor Elevates Risk Nationally

September 6, 2018

By Doug Barry and Alicia Gordon

A False Claims Act lawsuit was filed by a data analytics company alleging inappropriate business practices of Providence and its consultant, clinical documentation improvement company J.A. Thomas and Associates (“JATA”) now Nuance.

The lawsuit alleged that Providence’s false Medicare claims were not only intentional but were part of a systematic effort with JATA, to boost its Medicare revenue through up-coding inpatient claims.

A multi-faceted investigation, which included interviewing former employees, reviewing documentation training materials, and JATA’s CDI improvement program software, resulted in the following allegations:

  • Providence, aided by JATA, trained doctors to up-code
  • JATA’s software systematically promoted up-coding
  • JATA’s up-coding strategies extend beyond Providence

Most troublesome is the filed document contends that JATA trained CDI RNs are part of the clinical team and have more “leeway” by providing a different standard for nurses than coders. This lawsuit has had a far-reaching effect on CDI programs nationally, as facilities are initiating risk mitigation initiatives to evaluate any exposure. These allegations highlight the need for stronger compliance oversight and controls for CDI programs.

Based on the lawsuit, clinical validation through a data analytics approach is the first recommended step for assessing your potential risk exposure. Review of existing Clinical Documentation Improvement/Integrity (CDI) program processes, guidelines, policies and procedures, and query forms are also highly recommended to assure compliance with AHIMA’s Guidelines for a Compliant Query Practice (2016 update).

Conclusion

Current CDI practice may need to be revamped and additional education provided to assure program compliance. The goal of any best-practice CDI program is to support providers’ documentation efforts to most accurately depict the patient’s co-morbidities on presentation, what caused the encounter, what happened during the encounter, why all services were provided, and reflect patient-focused quality of care and the continuum of care upon discharge, which allows the most accurate code assignment and reporting of diagnosis and procedures.

As a leading change facilitator, Mazars USA LLP’s Healthcare Consulting Group can assist you with your effort to validate the integrity of your CDI Program. For more information about timely, valuable information and insights into policies, best practices and industry developments, visit mazarsusa.com/hc.

 


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Mazars USA LLP is an independent member firm of Mazars Group.

Legal and privacy policy    Contact us    Terms and Conditions