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Is Prime Healthcare Playing Medicare Like a Flute? Three Questions to Consider

Is Prime Healthcare Playing Medicare Like a Flute? Three Questions to Consider

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Jethro Tull, William Heisel, reporting on health, Medicare billing, Prime Healthcare, kwashiorkor

On Friday, I outlined the Jethro Tull Problem that looms over the current discussion of whether Prime Healthcare is overbilling Medicare for kwashiorkor and other disorders. Jethro Tull won the 1989 hard rock/heavy metal Grammy and enraged an entire generation of metalheads. If a guy playing the flute – no matter how vigorously – could be called heavy metal, then what did the word really mean?

California Watch has prompted a similar line of questioning with its stories showing how hospitals owned by Prime, particularly Shasta Regional Medical Center in Redding, have been claiming that well-fed adults suffer from a disease usually only found in children in famine-stricken parts of Africa.

Was Prime forced to bill for kwashiorkor, even though their patients did not have what most experts would define as kwashiorkor? This is likely going to be one of the big questions for the FBI, which has been following California Watch's stories and tracking down the people quoted to ask them about the billing practices.

Medicare clearly plays a role here because this explosion in billing started after Medicare made significant revisions to its billing codes for 2008. Medicare payments are based largely on two sets of codes. The Current Procedural Terminology (CPT) codes are set by the American Medical Association. And the International Classification of Diseases (ICD) codes are set by the World Health Organization in conjunction with agencies such as the U.S. Centers for Disease Control.

Certain combinations of diagnoses trigger certain codes and then payments based on those codes, as Kaiser Permanente's Gloryanne Bryant explains on the website for the American Health Information Management Association (AHIMA).

"In some inpatient cases a diagnosis of "protein malnutrition" may be documented, which would be assigned to code 260, Kwashiorkor.

But did the physician really intend for the diagnosis of kwashiorkor to be reported?" she writes. "Since kwashiorkor is not often seen in the United States, coding professionals should review the clinical documentation and clinical indicators carefully and ultimately query when clarification is appropriate." In other words, when in doubt, ask the doctor, because the doctor is most likely going to say, "The patient didn't have kwashiorkor."

So what should Prime hospitals be doing if they want to be paid by Medicare? There are a range of possible codes for protein problems, including the very open-ended "other protein-calorie malnutrition," "other and unspecified protein-calorie malnutrition," "unspecified disorder of plasma protein metabolism." There's also, crucially, this code: "other severe protein-calorie malnutrition," which is defined as "nutritional edema [or swelling] without mention of dyspigmentation of skin and hair." Kwashiorkor, on the other hand, is defined as the opposite: "Nutritional edema with dyspigmentation of skin and hair." Unless there are a lot of adult patients in Prime hospitals with skin and hair discoloration, Prime is going to have a hard time arguing with federal regulators that it is doing the right thing. Remember that it's not just kwashiorkor where Prime is out of line with other hospitals. It found autonomic nerve disorders in 40 out of every 1,000 Medicare patients at Chino Valley Medical Center, when hospitals on average found the disorder in fewer than 1 patient of every 1,000. Prime hospitals found encephalopathy 18% of the time while other hospitals found it 4% of the time. Three Prime hospitals are the top billers for malignant hypertension, all diagnosing it at more than 700 times the state average.

But could Medicare be wrong about these disorders? Absolutely. The science behind these diseases is one thing. The billing codes are another. Federal prosecutors are going after a Maryland hospital that also was billing at a high rate for kwashiorkor.  California Watch writes, "In the complaint, the government said Kernan Hospital in Baltimore fraudulently billed Medicare about $1.6 million for treating elderly patients for kwashiorkor, a nutritional malady that, according to experts, is widely associated with impoverished children in the Third World."

Like Prime officials, the officials at Kernan say they were just following the codes. To them, protein malnutrition in patients led to the kwashiorkor billing. "Hospital spokeswoman Mary Lynn Carver said in an e-mail that the hospital had conducted its own review of its malnutrition cases and reached ‘a substantially different conclusion' than the prosecutors. Carver noted that Kernan Hospital is known for rehabilitating patients with traumatic brain injury. ‘Many of the patients come to Kernan after prolonged hospitalizations, and 20 percent to 30 percent of our patients come to us on feeding tubes which can be a recommended treatment to combat protein malnutrition,' she wrote." The trick will be for Medicare and the FBI to figure out whether these hospitals were actually finding a billable protein deficiency or just writing "protein deficiency" in the patients' records to justify a Medicare billing.

And this brings us back to Jethro Tull. Even lead vocalist/flautist Ian Anderson was surprised to see his band competing against the likes of Metallica and AC/DC. Similarly, patients who are overweight and who did not go to a Prime hospital because of a malnutrition problem are surprised to find out that the hospitals billed Medicare for a disease they can hardly pronounce. Jethro Tull emerged triumphant, taking out ads that said "the flute is a heavy metal instrument."

Patients and taxpayers could also emerge triumphant if Prime's gambit forces Medicare to be more vigilant about billing discrepancies and transparent about the way it makes funding decisions. It should not take a news story for the agency to notice when billing for an obscure disorder is hitting new heights. And, if it does take a news story, the agency should talk about it. So far, it has rebuffed numerous requests from reporters to talk about what is going on. If Prime is doing things by the book, then the book may need revising.

Clearly, most hospitals are operating under a different set of assumptions about what the various protein deficiency codes mean. If Prime is not doing things by the book, then we may see some serious consequences for the chain and its hospitals in the months to come. In the meantime, Medicare should open the book to give the public a better understanding of how it is spending its billions.

What do you think about the kwashiorkor billing? And what's your favorite Jethro Tull album? (Mine is Thick as a Brick.) Leave your comments below. You can also follow me on Twitter @wheisel.

Related Posts:

Prime Healthcare's Jethro Tull Problem: Medicare Billing for Obscure Diagnoses

Slap: Talk With a Reporter, and Hospital Execs Will Expose Your Medical Records

Photo credit: Nickster 2000 via Flickr


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This points out a great problem in the realm of Medicare payment for health care. Medicare possesses a wealth of claims data, but they cannot seem to be able to identify anomalies that should raise questions and lead to further investigation. Instead, Medicare claims there is rampant fraud that leads to the contracting of other entities to do exactly what Medicare should be doing itself, data mining the wealth of data that it has in its possession to identify questionable billing. Some of the so called fraud in Medicare is coding errors, while some is inappropriate up-coding to increase the revenue stream from Medicare. Medicare can claim it is efficient in its administrative processing system, only because it fails to employ processes to identify problems but concentrates on paying claims. Conversley, providers like Prime and Kernan should not be allowed to just claim their systems produced these codes in "error." They should be held responsible to have systems that produce appropriate coding and identifies errors.

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More than "error" or "confusion" how about realizing it is fraud? How can any intelligent person believe that this man buys bankrupt hospitals, hospitals that professional medical CEO's etc. can not keep running and makes them profitable and him worth over $300,000,000??? Come on pull your head out. People have died because of their fraudulent practices and yet the medical board turns a blind eye and Medicare (who is handling your money) also sees nothing.

Time to wake up !

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