Upcoding: Surgeons rebel against management

Do you think pressure by management to upcode only occurs at this one hospital?

UVA Health Surgeons Sound Alarm on Upcoding

— Leaked meeting audio latest development in ongoing strife at health system, medical school

by Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today October 24, 2024

More light has been shed on [allegations of a toxic work environment (https://www.medpagetoday.com/special-reports/features/112141) at the University of Virginia School of Medicine and UVA Health.

About a year ago, surgeons had raised concerns that they were pressured by leadership to upcode in an effort to bring in more money…

Surgeons said there was “tremendous pressure” from senior leadership to charge patients more, particularly at the system’s flagship hospital UVA Medical Center in Charlottesville, according to the article. Doctors were told to do so by using the CPT code 99291, which indicates a doctor spent 30 to 74 minutes administering critical care services.

This code brings in $1,060 and 4.5 relative value units, while a similar code (99232) brings in only $200 and about 1.39 relative value units, the article stated… [end quote]

If this fraud is widespread it would add an immense amount to medical bills.
Wendy

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Rogue Capitalism!

The Captain

We live near UVA and have been reading about this for awhile. Some of the articles talk about the pressure to up code to compete with hospitals that were showing greater profits by upcoding. My guess is that it is widespread because of the corporate for-profit takeover of so many hospitals.

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If I found myself likely to be using this hospital’s services, my worry would be what appears to be concern over the quality of new doctor hires. Using the rationale that poor quality doctoring is more likely to put me in a position to require critical care services. If that were to happen, I think I’d be wanting the $1060 effort…at the very least.

On further checking…i.e. what the procedure codes actually are and what might make the difference between the two levels of reimbursement…I fancy the reporting might be a bit dodgy on this one (assuming the readership might be equally in the dark on billing and coding issues as I am, I expect) The $200 payment code (reimbursement just over $71 from Medicare!!!) bears no resemblance to critical care services as far as I can see.

medical coding level can either be based on time or complexity of decision making. There is a point based checklist based on the note generated from the encounter that drives billing based on decision making. So one doesn’t necessarily need to spend 30-74 minutes working to generate a 99291.

I remember Bill Esrey, former CEO of Sprint, saying, in retrospect, he couldn’t understand how Worldcom could generate the numbers they did. We found out: fraud. But this is Shiny-land. I bet no-one would lay a glove on Bernie Ebbers today. After all, he was a “job creator”.

Steve

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