DOJ Announces $117.7 Million Settlement to Resolve False Claims Act Allegations Against Aetna
Federal officials announced this week that one of the nation’s largest health insurers has agreed to pay $117.7 million to resolve fraud allegations.
The False Claims Act (FCA) case involved Aetna, Inc., which the U.S. Department of Justice (DOJ) said failed to withdraw inaccurate and untruthful diagnosis codes in order to increase the payments it received from Medicare, and falsely certified in writing to the Centers for Medicare & Medicaid Services (CMS) that their data was sound. READ MORE
When the Coding Guidelines Meet the Two Controlling Systems
In a recent article, I described a documentation environment governed by two distinct and often competing controlling systems. The first is the regulatory framework established through federal law: statutes, Conditions of Participation, program manuals, and enforcement guidance that define what the medical record must demonstrate to support a billed service. The second is the payor-driven system of coverage policies, medical necessity criteria, and prior authorization requirements that determine whether a service will be authorized and paid.
Understanding those two systems and the tensions between them is a necessary foundation for clinical documentation integrity (CDI) work. But there is a third layer of authority that operates across both areas, one that is often underestimated, precisely because it lives inside the coding profession, rather than in a compliance manual or a payor policy: the ICD-10-CM Official Guidelines for Coding and Reporting. READ MORE
Insight into a Payer’s Perspective: BCBS Claim Upcoding by Hospitals
Blue Cross Blue Shield published an article titled “Study suggests AI is boosting hospital billing.” The study was based on data analyzed by Blue Health Intelligence® (BHI®) which looked at claims data from “tens of thousands of maternity admissions.”
Not all clinical documentation integrity (CDI) departments review obstetrics cases, but when they do, as reflected in this report, acute blood loss anemia (ABLA) is an often-recorded secondary diagnosis, especially in women who deliver by cesarean section. READ MORE
Connecting Medical Necessity and Clinical Documentation
Hospitals often approach clinical documentation integrity (CDI) and utilization review (UR) as separate operational functions. CDI teams focus on ensuring that documentation accurately reflects patient acuity and supports coded diagnoses, while UR teams evaluate medical necessity and appropriate admission status.
Both groups spend a significant amount of time demonstrating their return on investment to their healthcare organizations, often through competing metrics such as increasing case mix index (CMI), decreasing observation rates, or improving physician-to-physician (P2P) overturn rates. READ MORE