Imagine if you create a stupid grading system and you pay hospital systems more for those at higher risk. How many of you think some of those hospital system would “fudge” those numbers to get paid more? Well, here is one example:
Sutter Health agreed to pay $30 million to settle allegations that the Sacramento, Calif.-based health system submitted inflated diagnosis codes to the CMS for Medicare Advantage beneficiaries, the Justice Department announced Friday.
The CMS pays private insurers a set amount per person to administer program benefits under Advantage plans and adjusts the payments based on “risk scores,” calculated using demographic information and health status data. Sutter and its affiliates contracted with certain Medicare Advantage organizations and received a share of the reimbursement for the beneficiaries under Sutter’s care.
But, hey, it’s only $30 million. That’s not as nearly criminal as a making 99213 to a 99214. That’s because you have no money to pay big lawyers to protect you. Not like these guys:
Neither Sutter nor its affiliated medical foundations admit any liability, the Justice Department noted in its news release.