Providence Health accused of $188.1M upcoding scheme: 6 things to know

Data analytics firm Integra Med Analytics filed a lawsuit against Renton, Wash.-based Providence Health & Services seeking $188.1 million related to alleged Medicare upcoding. 

Here are six things to know:

1. Integra filed a False Claims Act lawsuit Aug. 10 in the U.S. District Court of Central California against Providence Health & Services, which is now Providence St. Joseph Health. The lawsuit alleges Providence routinely used unwarranted major complication and comorbidity secondary codes on Medicare claims to inflate reimbursement.

2. According to the 100-page lawsuit, Integra discovered the unwarranted secondary codes during an analysis of Medicare claims dating back to 2011. Integra said an investigation of the business practices of Providence and its consultant, clinical documentation improvement company J.A. Thomas and Associates, "confirmed that Providence's false Medicare claims were not only intentional but were part of a systematic effort to boost its Medicare revenue."

3. The lawsuit specifically alleges Providence and its consultant were "pushing doctors to make unwarranted diagnoses" and "using leading queries to change doctors' original diagnoses." Integra claims JATA's proprietary software also was made to manipulate diagnoses.

4. Adding a complication or comorbidity secondary code to a Medicare claim can result in an increased claim value of between about $1,000 and $10,000, according to the lawsuit. Adding a major complication or comorbidity secondary code can result in an increased claim value of between $1,000 and $25,000. Integra said it found 1,429 of Providence's more than 11,000 claims involving a femoral neck fracture had an accompanying secondary major complication or comorbidity of encephalopathy.

5. Overall, Integra seeks to recover more than $188.1 million paid by the federal government in connection with Providence's actions.

6. A Providence spokesperson told Becker's Hospital Review hospital officials received a partial version of the complaint this week and are thoroughly reviewing the allegations. "Prior to that review, we reiterate that Providence St. Joseph Health follows rigorous standards for Medicare reimbursement claims, based on all relevant regulation and supported by our core values. The government has declined to be a party in the litigation and we will proceed based upon our review and how and if the case moves forward," she said.


More articles on legal and regulatory issues:

Ex-CEO pleads guilty in kickback case involving California health clinics
Illinois physician claims imitator wrecked his career
12 latest healthcare industry lawsuits, settlements

Copyright © 2022 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.


Featured Whitepapers

Featured Webinars