At a campaign stop in rural Waterloo, Iowa in late August, Republican Sen. Joni Ernst told a crowd of nearly 100 people that she believed healthcare providers were inflating COVID-19 death counts for profit.
"These healthcare providers and others are reimbursed at a higher rate if COVID is tied to it, so what do you think they're doing?" she said, according to a report by the Waterloo-Cedar Falls Courier.
Ernst is fighting to keep her seat in one of a handful of competitive races that will determine control of the Senate in November. Her comment is the most prominent instance yet of Republican politicians parroting politicized misinformation about healthcare providers' reporting of COVID-19 cases. Medicare payment policy enacted by Congress to help struggling providers has become distorted as conspiracy theorists, including QAnon followers, tried to undermine COVID-19 death counts.
American Hospital Association President and CEO Rick Pollack in a blog post denied that hospitals are over-reporting COVID-19 cases for profit.
"The professionals of America's hospitals and health systems are focused on saving lives and treating illnesses – period. They shouldn't have to waste precious time debunking theories that are offensive and untrue," Pollack said.
The discourse has had real-world consequences, as CMS recently required healthcare providers to obtain a positive COVID-19 test to get additional Medicare reimbursement and a HHS watchdog announced an audit into coronavirus-related inpatient hospital billing.
Seeds of doubt
The roots of the accusation that providers may be upcoding to take advantage of additional reimbursement for COVID-19 cases comes from television appearances in early April by Republican Minnesota state Rep. Scott Jensen, who is a family physician.
Jensen and Fox News hosts made comments on April 7 implying that COVID-19 death numbers could be inflated. Jensen raised concerns in an interview with a local news station based in North Dakota about Centers for Disease Control and Prevention guidelines that allowed physicians to list COVID-19 as a "probable" or "presumed" cause of death even if a definite diagnosis could not be made.
The next day, National Institute of Allergy and Infectious Diseases Director Anthony Fauci dismissed the concerns about inflated death counts.
"You will always have conspiracy theories when you have any challenging public health crisis. These are nothing but distractions," Fauci told reporters.
That evening, Fox News host Laura Ingraham invited Jensen to appear on her program. Jensen claimed that the CDC guidelines for death certificate completion allowed healthcare providers to "massage and sort of game the numbers," and implied that upcoding by healthcare providers may be financially motivated because Medicare pays a 20% Medicare inpatient add-on payment for cases of COVID-19.
"I would remind him that anytime healthcare intersects with dollars, things get awkward," Jensen said in response to Fauci's dismissal.
The right-leaning news website The Spectator picked up and amplified claims from Jensen's interview in an article headlined "Hospitals Get Paid More to List Patients as COVID-19 and Three Times as Much if the Patient Goes on Ventilator."
Jensen continued his campaign of skepticism on social media. In a Facebook post on April 15, Jensen said that jockeying for federal provider relief funds could incentivize states to inflate death counts and linked to an article published by the U.S. branch of RT, a news network owned by the Russian government. In a video posted April 19, Jensen claimed he wasn't accusing physicians of lying on death certificates, but said they could have been pressured by hospital administrators to get larger lump-sum payments from Medicare.
"Hospital administrators might well want to see COVID-19 attached to a discharge summary or a death certificate," Jensen said.
Jensen disclosed that the Minnesota Board of Medical Practice investigated two complaints regarding his comments about COVID-19 and dismissed them in July. On Sept. 5, Jensen said on Facebook that the state medical board has undertaken another investigation.
In an interview with Modern Healthcare, Jensen said he did not intend to accuse hospital administrators of anything wrong or fraudulent, but to point out that administrators may face a perverse incentive to code for COVID-19 if situations are ambiguous.
"I don't think it makes a whole lot of sense to accuse someone of doing something there is no evidence that they did, but it does make sense to have a discussion as to how a door has been opened," Jensen said.
It is true that Congress created an 20% Medicare add-on payment for inpatient COVID-19 cases in the Coronavirus Aid, Relief, and Economic Security Act. Becky Greenfield, a healthcare associate at Wolfe Pincavage, said the additional payment was created to account for the nature of COVID-19 as a novel, complex disease that comes with many complications.
If hospitals are caught upcoding or miscoding patients, they could face False Claims Act liability and ultimately risk losing their Medicare and Medicaid licensure, Greenfield said.
"As a hospital that would be devastating, and those risks alone would outweigh any potential benefits of misrepresenting a patient's COVID-19 status," Greenfield said.
While the CDC guidelines for adding COVID-19 to death certificates were unorthodox, the agency was likely trying to account for issues with the availability and reliability of COVID-19 tests, said Katherine Drabiak, an associate professor at the University of South Florida College of Public Health and College of Medicine.
"If it's something like choosing between COVID-19 or pneumonia, it can be difficult to disentangle what was the cause of death if a COVID-19 test has returned a false positive or negative," Drabiak said.
There could have been some economic pressure to designate patients as having COVID-19 as hospital administrators faced massive volume losses in the early days of the pandemic, but Drabiak said it was unlikely anything "nefarious" was going on.
Overall, analyses of deaths in 2020 compared with prior years appear to show that COVID-19 deaths may be undercounted. A New York Times analysis found that through Aug. 22, excess deaths were about 40% higher than the official COVID-19 death toll.
Political posturing over providers' incentives to upcode COVID-19 claims for profit cropped up again on May 26, when Rep. Glenn Grothman (R-Wisc.) asked a top official at HHS' Office of Inspector General about potential perverse incentives for healthcare providers.
"We are monitoring through our data accompanying bills and claims with a COVID diagnosis as a way to potentially upcode," Principal Deputy Inspector General for HHS Christi Grimm told members of the House Committee on Oversight and Reform.
In August, the OIG added an audit of hospital billing to its work plan to ensure billing complied with federal requirements. A report on the audit is projected to be released in 2022.
CMS also announced that as of Sept. 1, healthcare providers have to provide documentation of a positive COVID-19 test to receive the 20% Medicare add-on payment. CMS said the agency made the change to address "potential Medicare program integrity risks." Hospitals opposed the new policy and voiced concern about the added administrative burden.
"CMS remains committed to safeguarding taxpayer dollars and strengthening program integrity in our operations and to ensuring that the medical review of patient health care claims continues while minimizing provider burden as much as possible," a CMS spokesperson said.
Greenfield said the new CMS policy appears to be some kind of response to the fringe conspiracy theory that hospitals are misclassifying patients as COVID-19 positive in order to get enhanced payment.
Death toll conspiracy
The political discourse was pulled further toward the fringe when conspiracy theorists in late August distorted data from a CDC report and tried to falsely claim that only the 6% of COVID-19 deaths listed with no comorbidities should have been counted in the COVID-19 death toll.
Some of those conspiracy theorists were followers of QAnon, set of conspiracy theories falsely alleging, among other things, that prominent Democratic politicians and celebrities are involved in a global child sex-trafficking operation. The ideology glorifies President Donald Trump as leading the fight against the supposed criminal activity.
Trump retweeted a QAnon follower that made false claims about the CDC's COVID-19 death statistics, and Twitter removed the tweet on Aug. 30 for violating rules about disinformation.
Jensen said he thought the conflation between his comments about CDC guidelines for completing death certificates and distortions of CDC reports on comorbidities was "terribly unfortunate."
"The idea that the 6% alone were supposed to be interpreted as COVID-19 deaths and not the rest of them is wrong, and I never said it," Jensen said.
The combination of the two theories crystallized in Ernst's comments. After saying at an Aug. 31 campaign stop that she was "so skeptical" of death counts, her office walked back the implication.
"Over 180,000 Americans have died because of COVID-19, and what matters is that we are getting the resources to Iowa that are needed to fight this virus and continuing to support our health care workers on the front lines, and that's what I'm focused on," Ernst said in a written statement.
Ernst faced swift backlash. Her opponent seized on the comments and ran a Facebook ad accusing Ernst of "peddling dangerous conspiracy theories." A group that represents 6,000 physicians, residents and medical students in Iowa called Ernst's comments "offensive," according to a report by the Quad-City Times. The Iowa Medical Society said Ernst apologized for her remarks but did not promise a public apology.
The American Hospital Association weighed in shortly after Ernst's comments, saying that "disturbing and disproven" theories had circulated about the COVID-19 death count. Pollack wrote in a blog post that hospitals and health systems adhere to strict coding standards.
"Hospitals do not receive extra funds when patients die from COVID-19. They are not over-reporting COVID-19 cases," Pollack said.