While Columbia/HCA Healthcare Corp. draws legal and media attention for allegedly manipulating DRG codes to increase Medicare payments, another possible "upcoding" scandal is brewing in Washington.
MODERN HEALTHCARE has learned HHS' inspector general's office is claiming to have found a pattern of upcoding by some of the nation's teaching hospitals.
The claim is an outgrowth of HHS' ongoing Medicare billing investigation of teaching hospitals and their faculty practice plans.
The investigation, which began in fall 1995, centers on how hospitals and faculty practice plans bill Medicare for the work done by medical residents.
According to HHS, teaching physicians that bill Medicare for work done by residents are double-billing the program because that work is paid for through graduate medical education payments to hospitals.
Recently, representatives of teaching hospitals and their faculty practice plans have been pressuring Congress to get HHS off providers' backs. HHS, in turn, has been defending its work to the same lawmakers and now is claiming that it's onto something really big.
According to several sources who have met with the inspector general's office, federal investigators are claiming they have found a pattern of Medicare overbilling by teaching hospitals that's far more extensive than originally suspected.
According to several congressional aides who have met with representatives from both the Association of American Medical Colleges and HHS, the inspector general's office is claiming that nearly half the billing problems it's uncovering have to do with upcoding by teaching hospitals.
Furthermore, according to sources who have met with federal investigators, the inspector general's office claims that, while in most investigations the instances of overbilling are substantially offset by instances of underbilling, in the case of teaching hospitals the ratio is 90% overbilling to 10% underbilling.
Officials from the inspector general's office were not available to comment on the investigation or on the meetings.
The AAMC, which has claimed that the agency's investigation is moving way beyond its original scope, has been pressuring lawmakers to take a close look at the probe.
"We are drowning in paper from both sides," said one Democratic aide. "There are questions about both (the inspector general and the AAMC) stories. I am not sure if members (of Congress) are willing to put their necks on the line until it becomes clear who is telling the truth."