The Justice Department and the Department of Health and Human Services concluded that the Good Samaritan Hospital used leading questions in determining that some patients were suffering from malnutrition. Federal investigators accused the hospital of committing Medicaid and Medicare fraud based on the enhanced reimbursement rate the hospital could claim for patients due to the malnutrition finding. The hospital agreed to pay nearly $800,000 in penalties to settle the matter while stating, “We have provided the highest level of quality care to our patients in accordance with all laws and regulations.”

A similar case may point out a common element in many health care fraud situations. The coding system used in billing for Medicaid or Medicare eligible services is complex. Human error can expose medical professionals and hospitals to substantial penalties associated with fraud. A University of Maryland hospital also stands accused of improperly diagnosing patients with malnutrition. The Justice Department is seeking $8.1 million in restitution, despite the fact that the hospital claims the coding system itself is to blame. Apparently, more than one health condition was granted the same code number, making it appear that “malnutrition” was diagnosed more often than it was.

The Medicaid and Medicare programs have expanded enormously in a short period of time. While it is certainly important for health care providers to make efforts to bill every condition appropriately, it should not be too much to ask that the system be comprehensible. Doctors, nurses and other care providers should not risk massive civil and criminal penalties every time they make an honest attempt to file a claim.

Source: Baltimore Sun, “Good Samaritan Hospital settles claims it defrauded health programs,” by Meredith Cohn, 28 March 2012

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