December 18, 2011
Shasta Regional Medical Center in Shingletown, Cal. is accused of billing for services not provided. Darlene Courtois is an overweight patient on Medicare who was seen for a fall, was billed for services for Kwashiorkor, an illness in which the victim is severely malnourished. In November 2008, the hospital reported eight cases of kwashiorkor, over the next two years the hospital reported more than 1,030 cases. This is more than 70 times the statewide rate (Williams, 2011). In this particular case the medicare reimbursement increased by more than $6,700 with kwashiorkor as the diagnoses. Upon further investigation, doctors noted reveal that the patient has protien malnourishment. She received diet counseling and adjustment as part of her care (Williams, 2011). Last year the hospital was under investigation due to a surge in blood infections. Prime officials have stated that these statistics simply mean they are serious about malnutrition rates amoung the elderly. Officials deny any false documentation, insurance fraud, or any other wrong doing. Patients with low levels of protien, iron, albumin, or other low nutrient levels but were otherwise nourished have been coded with the diagnosis of kwashiorkor (Williams, 2011).
What is the issue
In this case the administrative ethics involve patients records containing incorrect codes for unneccessary services, causing insurance to pay out more on their behalf. This is unethical because the hospital is commiting insurance fraud. This issue effects not only those on Medicare but also those who do not. In many instances the article states that although the patient may not have been suffering from kwashiorkor, she had a low nutrient that administrative personnel coded as kwashiorkor (Jewett, 2011). This causes confusion within the administrative staff because there are no codes for protien malnourishment or low iron. Many coders are told to code and bill for kwashiorkor if a patient falls into certain categories (Jewett, 2011). With this the confusion with ethics begins.
It is the responsibility of the doctor to ensure that the diagnosis is correct to the best of his/her knowledge, and that the administrative staff are coding procedures properly. It is also a matter of accountability on the administrative assistants behalf to check the record and ensure that the information they are receiving matches what is on the patient records. Members of the staff should be accountable for accuracy of the patient record and insurance procedures. The hospital compliance and ethics committee should also check back with the patient to ensure that the information in their records are the services he/she received.
If the problem indeed exsists with the coding structure rather than the hospital ethics, Medicare, Medicaid, and other insurance companies should look at adding more specific codes to their billing procedures, such as those for nutrient defieciencies.This could help prevent further accusations of insurance fraud. There are other conditions in which coders are urged by Prime Healthcare Systems to code simply because a patient displays a symptom (Jewett, 2011). There should be a minimum number of symptoms that a patient must have to be defaulted to that condition. For instance, a woman misses her monthly mensus, although a common symptom of pregnancy, does not mean that she is pregnant. Insurance companies should also have a policy in place that allows only so many cases of an illness in one hospital before investigating the credibility of the claims.
Because of the investigation, many coders and hospital administration have resigned. In an interview with California Watch, a former employee recalls times that a doctor instructed her on how to code the diagnosis so that the medicare pay out was of more benefit to the hospital (Jewett,