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UnitedHealth Group, Inc. vs. the United States of America: The case for CDI, part 2

Brian-Murphy

ACDIS Director Brian Murphy

By Brian D. Murphy

In Part 1 of this series I introduced the developing story of UnitedHealth Group, Inc. vs. the United States of America, and my intent to write a series of articles on this civil fraud action. Why? Because I find this to be an incredibly interesting case with broad ramifications for CDI and coding departments.

So let’s review the basic at the facts of the case, starting with the who and when. [more]

UnitedHealth Group, Inc. versus the United States of America: The case for CDI

Brian-Murphy

ACDIS Director Brian Murphy

By Brian Murphy

The work of a CDI professional can at times seem isolating and unimportant. Does it matter if a query gets answered? When we educate physicians and tell them what they document matters, are they listening?

Then a case comes along and demonstrates not just that the CDI profession does matter—but that it matters a lot.

That point was driven home to me while reading a May 16, 2017 court document, United States of America ex rel. Benjamin Poehling v. UnitedHealth Group, Inc., in which the Department of Justice (DOJ), alleges that UnitedHealth artificially increased Medicare Advantage (MA) reimbursement/Hierarchical Condition Category assignment by mining for non-supported diagnoses that were not documented/reported by the physician or through chart documentation.

The case is a qui tam—a lawsuit brought forward by a private individual. The plaintiff is Benjamin Poehling, the former Director of Finance for UnitedHealthcare Medicare & Retirement (and its predecessor Ovations), which was the group at United that managed its MA plans and its Medicare Part D prescription drug programs.

The lawsuit seeks to recover more than $1 billion under the False Claims Act. The total damages sought are unspecified but it’s a large case with a lot at stake.

This case has received quite a bit of coverage, too, from big newspapers like the New York Times and popular healthcare websites like Beckers Hospital Review and HealthLeaders Media.

There is a lot more to this case than this 103-page court document, though. In addition to Poehling’s case (filed in February 2017), another whistleblower, James Swoben, a former employee of Senior Care Action Network Health Plan and a consultant to the risk-adjustment industry, came forward with similar allegations in March.

In a very recent development, UnitedHealth Group’s lawyers are seeking to get the case dismissed, claiming that they are not required to validate the accuracy of diagnostic data submitted by healthcare providers.

I need to reiterate that, at this point, the claims asserted against UnitedHealth Group are only allegations and there have been no determinations of liability. It remains to be seen whether the case will even reach court.

However, the case ultimately resolves, it’s a very interesting, real-world, big-dollar example of the business of healthcare, raising the question of who is ultimately responsible for the accuracy of submitted diagnoses to Medicare (coders, CDI, administrative contractors, physicians?). It calls into question the oft-repeated adage that coders must code what the physician documents. It brings into even greater prominence the process of clinical validation, for which ACDIS recently released a new white paper.

Reading through these articles and the original court document, I thought to myself, if only UnitedHealth Group had a robust, compliant CDI process in place, this suit could have been prevented. More than anything, United States of America vs. UnitedHealth Group Inc. is confirmation that your work as a CDI professional matters, and that the broader CDI profession matters.

I plan to share my thoughts on this case in a series of blog posts here and I welcome your thoughts and commentary.

Editor’s note: To read the summary of the case, visit the DOJ website by clicking here. To read the court document in its entirety, click here. Brian Murphy is Director of the Association of Clinical Documentation Improvement Specialists (ACDIS). He can be reached at bmurphy@acdis.org.

 

 

Q&A: Coding chronic kidney disease, hypertension, and diabetes mellitus

LauriePrescott_May 2017

Laurie L. Prescott, RN, MSN, CCDS, CDIP, answered this question

Q: Let’s say a provider documented chronic kidney disease (CKD), 2/2 hypertension (HTN), and diabetes mellitus (DM), and the stage of CKD was not specified, but lab results show patient was in stage 2. Could I assign codes for CKD, stage unspecified, Hypertensive CKD w/ stage 1-4, and Type II DM. Do I need to assign a separate code for HTN?

A: Let’s break down the documentation.

CKD secondary to HTN and DM: With this documentation, we have two combination codes to assign—hypertensive CKD and diabetic CKD. We would also assign a code to reflect the stage of the CKD.

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Note from the Associate Editorial Director: A Little Local Chapter Love

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Associate Editorial Director Melissa Varnavas grabs a picture with a Local Chapter leader from Kentucky at the 2017 Conference!

By Melissa Varnavas

Next Friday, August 11, ACDIS Editor Linnea Archibald and I will head down to Newton, Massachusetts for the third-annual joint ACDIS/AHIMA New England CDI Symposium. The leaders of the MaHIMA, NYHIMA, and MA ACDIS have met for months to develop a comprehensive agenda to fit the educational needs of both coding and clinical documentation professionals.

The full-day event, sponsored by 3M, was originally the brainchild of then ACDIS Advisory Board member Walter Houlihan, director of HIM for Baystate Health in Springfield, Massachusetts. Houlihan, at the time, served as the president of the MaHIMA and, although his time in that role was ending, he had yet to see his vision for a multi-state event come to pass. After mentioning his hopes in a passing phone call, we decided to see if we could, in fact, bring this idea to fruition. The first year, more than 100 attendees arrived. The second held nearly 160. Baystate Health generously hosted those first two events.

This year, attendance has topped 200 and the registration has closed due to the constraints of the room size (although there is a wait list).

This is an amazing story about the importance of collaboration and the value of networking and education in our tiny slice of the healthcare industry we serve. And it’s a story that’s not just happening in New England but is playing out across the country. Every week in this email newsletter, we list local chapter upcoming events and offer a tip or tale about what’s happening at the local level. Recently, on ACDIS Radio, we remarked about the number of full-day events coming up.

In August, not only do we have the New England event but also North Carolina and Florida are holding full-day educational sessions. In September, both California and Alabama hold full-day events. The California event will be its third annual, and generally gathers more than 200 attendees. The leaders from each of the three Missouri ACDIS chapters have been meeting for more than a year to plan their big full day event coming up in October. Last year there were nearly 150 attendees and this year they expect to reach 200 attendees as well. South Carolina and Oregon also hold events in October and although it’s still in the planning stages, Texas hopes to have a full-day event in October too.

These volunteer leaders have done a tremendous job planning these events for the benefit of their communities. We cannot thank them enough for their efforts and hope that you, too, reach out to them, volunteer, attend, extend your own involvement in this, our ever growing, ACDIS community.

Editor’s Note: Varnavas is the Associate Editorial Director for ACDIS. To find out about what’s happening in your neighborhood visit the local chapter page. To learn more about starting a chapter or networking group, scroll down below the map to read our local chapter leadership resources. Contact her at mvarnavas@acdis.org.