In a healthcare fraud audit, the government is reviewing patient documentation for evidence of fraud.  Is the provider billing for care solely to increase their payments or is the care provided appropriate for the patient?  Documentation is often the key.  If your documentation is lacking, the government will claim you committed fraud.

“Beth Israel Deaconess Medical Center has agreed to pay $5.3 million to the federal government to resolve allegations that it violated the False Claims Act by billing Medicare for inpatient stays that should have been treated as outpatient or observation cases.

But Beth Israel says that what the U.S. Attorney’s office calls fraud, the hospital calls quality care.

A statement from Beth Israel reads in part, “Indeed, during the inquiry, BIDMC vigorously defended claims for an inpatient level of service delivered to patients whom physicians had concluded should be admitted to the hospital because of their condition Under the settlement, BIDMC admits no liability whatsoever.”

From Boston Business Journal July 29, 2013

One might wonder how and why a hospital has $5 million dollars to pay the federal government for something they insist THEY DID NOT DO.  Well, there are actually a lot of good reasons.  Healthcare fraud charges often are assessed at 3 times the amount wrongly billed to the federal government.  This is called “treble damages” and is often at the discretion of the government.  The law is written with this extreme penalty to discourage healthcare providers from engaging in fraudulent activity.

The government reviews hospital medical records long after the patient care is provided.  The auditor often determines that there is no medical documentation to support the costly admissions to the hospital or the care is more properly handled at a much cheaper out-patient basis.  The medical billing rules are very strict.

The healthcare provider must clearly document the need for the hospital admission and all care provided during the length of stay.  If the medical chart doesn’t reflect the medical necessity for the admission, the stay is deemed unnecessary and therefore, improperly paid.  In some cases, the government says the care was unnecessary and was provided merely to obtain more money.  Hospitals often decide to settle the case and pay the government rather than to take the chance that they will be found liable for “fraud.”

Morale of the story:  DOCUMENT, DOCUMENT, DOCUMENT….



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