Bombshell ACO Whistleblower Lawsuit Highlights Needs for Accuracy, Not Maximization, of Medical Coding

Note: The following is an editorial and should not be substituted for legal advice or counsel.

By Brian Murphy

If you’re using a vendor promising “big ROI” from their revolutionary coding software—one that requires harried physicians to pick medical codes from dropdown lists—you are setting yourself up for huge fines and public humiliation.

We’ve seen this story played out again and again, but here it is one more time, courtesy of some fine reporting by Fred Schulte of KFF Health News: “Whistleblower Accuses Aledade, Largest US Independent Primary Care Network, of Medicare Fraud.”

Read the article here. It’s worth your time.

Here’s some examples of what Aledade is being accused of:

  • Conflating anxiety into depression to boost payments by $3,300 a year per patient
  • Categorizing patients over 65 years old who said they had more than one drink per day as suffering from substance use issues, to net an additional $3,680 per patient

According to KFF, “Aledade helps manage independent primary care clinics and medical offices in more than 40 states, serving some 2 million people … the lawsuit also names as defendants 19 independent physician practices, many in small cities in Delaware, Kansas, Louisiana, North Carolina, Pennsylvania, and West Virginia. According to the suit, the doctors knowingly used Aledade software to trigger illegal billings, a practice known in the medical industry as “upcoding.” None has filed an answer in court.”

Huge caveat: This is an open lawsuit and an active case. Aledade, a large accountable care organization (ACO) will get its day in court, and may win. Or, it may decide that paying a fine is less expensive than a protracted trial with an uncertain outcome.

But this is one more telling example in an ever-lengthening list of alleged Medicare Advantage abuses and upcoding. More than two dozen and counting.

Here’s what I know, from my 20 years in CDI and coding.

Good human beings with training and a conscience, committed to thoroughness and clinical accuracy, will get you the ROI you need (and are legally entitled to).

Not AI powered software that highlights words from an encounter or medical record and “suggests” different codes because they may pay more. AI does not think, it cannot contextualize or account for nuance or error, and it never admits to a mistake. It never says, “I don’t know.” It is in fact, not intelligent, it’s merely a prediction device, and it always requires human oversight.

Use them without coding professionals at your peril.

Likewise, coaching providers to pick ICD-10 codes because they’re designated as an HCC but do not represent clinical reality constitutes fraud. Instead, coach providers to use coding terminology that reflects clinical reality.

There is an endgame to coding. You can’t revenue maximize forever. Not every chronically ill patient is walking around with a nest of complications.

Good coding and CDI professionals know this.

Do the right thing.

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