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Viewpoint: $65M False Claims Act lawsuit shows need to improve coding & CDI compliance — 4 takeaways

In August, Ontario, Calif.-based Prime Healthcare Services paid $65 million to settle allegations it violated the False Claims Act by admitting patients who only required outpatient care and engaging in upcoding. 

This and other legal actions revealed a need to strengthen coding and clinical documentation improvement compliance programs, ICD-10-CM/PCS Trainer Gloryanne Bryant said in an article on ICD10monitor.

Here are four takeaways:

1. Practices with an established coding compliance program should rethink the program in light of recent legal actions. Assess the results of education and training and critically examine the results of auditing and monitoring processes.

2. Review any written policies and procedures for accuracy, relevance and adherence to coding guidelines and ethical standards.

3. Be cautious about setting finance-oriented metrics or goals or coding and CDI. Don't let coding and CDI efforts be dedicated solely to one payor, such as Medicare, and ensure there's a reliable quality assurance process in place for physician querying.

4. HHS' Office of Inspector General provided guidance to help prevent fraud, waste and abuse, including a series of documents published from 1998 to 2008 that apply to various healthcare segments. Review the OIG's guidance, which includes designating a chief compliance officer, distributing standards of conduct and maintaining a complaints process.

More articles on coding, billing and collections:
Why ASCs should be watching New Jersey's out-of-network billing law — 5 insights
4 ways ASCs can overcome common revenue cycle obstacles
ESEC Surgery Center correcting CMS violations after losing Medicare payments — 6 insights

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