When you read this, what’s the first thought I think of, attorneys and legal interpretations.  You reach a point to where you can go back and forth and back and forth on the audits.  This makes it hard for hospitals to budget and I have written about this before and really there should be some statute of limitations here and a look at reality. This could go on forever when you run analytics and you might spend a couple million on the project to get back a half a million so does that make sense?  Last month we had this statement and again it is due to the election for the most part as costs went up and let’s don’t mention that more doctors and hospitals are using electronic medical records that connect to coding systems so they get it right according to the rules established by the doctors and hospitals. 

HHS and DOJ Send Letters to Hospital Trade Associations Warning of Gaming Billing System Via Use of Electronic Medical Records–Hospitals Just Learned How to Bill Better & Hired Consultants–Case of Being Algo Duped With Numbers?

This was weak and again an emotional kind of witch hunt as someone felt compelled to find a goat here as there were no specifics mentioned.  In a lot of instances 3rd party consultants are used by hospitals as well to help them, and remember part of their sales pitch is “saving money”.  Everybody has a focus and the analytics don’t see the entire “human side” of this either, just dollars and parameters set in software configurations. 

Bad Algorithms in Healthcare Payment Systems and Risk Assessments–Did the Hospital Bill Fraudulently or Were They Sold Formulas That Did Not Conform

Next week we could be back to the re-admissions algorithms, again formulas that keep the money shifting, so if the government were a business what do you think they would do?  A business if it was not profitable and poured too big of an expense and hassle on their clients would probably move on.  Hospitalists go through this re-admissions documentation all the time and shoot even the hospitals and doctors have trouble understanding what insurers want and don’t get straight answers either, because of complexities.

Medicare Re-Admissions Penalties–Algorithms Keep Money Shifting and Make It Difficult for Realistic Budgets to be Met Along With Good Patient Care–Algos Keep the Money Moving In One Direction or Another

If this were to really be pursued, get the 3rd party consultants who advise hospitals and see what they have going and what they are advising hospitals.  So many of these consultants work right on the floors of the hospital any more so they can see and advise and few are subsidiaries of insurance companies. 

The Medicare Contractors are subsidiaries of insurance companies so if it was their auditors doing the work, what’s up with that?  I’m not talking about the obvious “fraud” cases where business intelligence software can nail those down because they exist too but the “billing” audits on some of this can go on for lifetimes.  Here’s an example with Mayo clinic.  Upon discovering a billing error in 2007, Mayo promptly corrected it and voluntarily refunded $262,975 to the government.  This case looks like the needed more money to pay the whistleblowers and it settled up with Mayo paying $1 million on top of what they originally paid.  You just have to ask since this began in 2007 was all this time and effort and paperwork to get $1 million worth it?  It was a billing error.  This is what I mean by shifting money back and forth and it went on for 5 years.  Mayo sent money, take it and settle the case and move on.   

Mayo Clinic Agrees to Settle DOJ Legal Suit Dating Back to 2007 Under Whistleblower Provisions–One More Example of Algorithms Shifting Money in Healthcare As Cost of the Lawsuit Had to Far Exceed the End Results With Time and Money–A Waste

How important is it that we have “perfect claims” going back how far and how much time is going to be spent I think is a good question to ask.  By the time you audit all the hospitals in the US this can go on for years and years.  Again I understand that auditors are paid to do a job and that’s what they do under someone else's direction so somebody has to make this call on the parameters of the audits.  BD


The American Hospital Association sued the agency that oversees Medicare, saying an audit program aimed at trimming improper payments is unfairly depriving hospitals of reimbursement for care they provide. 

The suit, filed Thursday in U.S. District Court for the District of Columbia, targets the federal Department of Health and Human Services, the parent agency of the Centers for Medicare and Medicaid Services. In addition to the association, the plaintiffs include hospital operators in Michigan, Missouri and Pennsylvania.

The suit focuses on the Recovery Audit Contractors program, which involves third-party contractors that review Medicare payments to hospitals. According to the suit, many hospitals have faced rulings by the auditors that care provided and billed on an inpatient basis should have been performed in an outpatient setting. Hospitals are then forced to return the money paid for the services.



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