Kwashiorkor and upcoding are not household words in the U.S. Many folks in the healthcare industry know the terms however. And in a weird way, they are usually related, at least in this country. We will start with Kwashiorkor first.
Kwashiorkor is a severe form of malnutrition commonly found in very poor, developing countries. In layman’s terms, it is the medical term for starvation. Thankfully it is rarely found in the U.S.
Although several of the medical professionals I know have never seen a case here, some Medicare billing records suggest a third of older Americans are suffering from the disease. In fact, some hospital billing record show that it has become an epidemic.
In 2009, reports began surfacing of several hospitals that were seeing alarming rates of kwashiorkor. At first Medicare regulators were concerned about these sudden pockets of newly discovered severely malnourished people. Soon, however, the truth came out. The diagnoses were probably severely exaggerated.
The Department of Justice is poised to go to trial in 2018 against Prime Healthcare, the operator of several hospitals in California and elsewhere. In 2008 there were almost no cases of this horrible disese in Redding, California. After the local hospital was purchased by Prime Healthcare, reported cases of severe malnutrition exploded. The same hospital now had 1030 cases!
Lest you think that Redding is a poor area or has millions of residents, one media report says the 1030 cases came from a town with about 90,000 people and a then median income of $62,222.
At one point, over 16% of the hospitals Medicare patients were essentially in the hospital because they were starving. Diagnosis rates were also much higher than average in several other hospitals owned by Prime. By our own research, even the poorest of poor areas in the U.S. didn’t have such ridiculous kwashiorkor rates.
Another media report says that a different Prime hospital in Huntington Beach reportedly claimed that 39 percent of its Medicare patients were severely malnourished. Huntington Beach, by the way, has an average income of over $100,000 per year.
Prosecutors say that one of Prime’s patients allegedly treated for kwashiorkor was actually obese, received no nutritional consult and was given no vitamins.
Prime was sued by a whistleblower in 2011. The company denies any wrongdoing. That case is now unsealed and heading to trial in 2018. We are smart enough to know, however, there is a problem when thousands of people are suddenly being diagnosed with an extremely rare condition.
So why would Prime Healthcare or any other provider suddenly diagnose so many people with starvation? The answer is simple. Money.
Medicare pays a lot of money for starvation cases. They require intensive management and often long hospital stays. There are often many complications from starvation. When your body is deprived of so many nutrients for so long, organs begin to fail. Hospitals can make a windfall when otherwise healthy people are diagnosed with kwashiorkor, however.
But what about the patients? Unfortunately, the doctors that are admitting these folks with a false diagnosis are not doing them any favors. Most people don’t like being hospitalized and certainly don’t like the increased risk of infection associated with hospital stays.
The Prime case is old news. We know there are still thousands of similar Medicare frauds involving upcoding, however.
Upcoding and Medicare Fraud
Upcoding takes place when a healthcare provider charges for a higher level of service than provided. For ladies, it is like getting billed for both a manicure and pedicure but only receiving one of the services. In the healthcare field, it could be a therapist that bills a 30 minute group session as if she performed a 60 minute intensive one-on-one session or a hospital that pushes doctors to admit patients with diseases they don’t have. Upcoding takes place thousands of times daily in the healthcare field throughout the United States. It is also against the law.
Under the federal False Claims Act, whistleblowers that report these schemes can earn an award of up to 30% from whatever is collected from the wrongdoer. To earn an award, however, you must have inside information regarding the fraud, file a sealed lawsuit in court and be the first to file.
Whistleblowers do a great service for the community. Not only do they stand up to greed and fraud and save taxpayers money, in healthcare cases they often save lives too.
MahanyLaw – America’s Whistleblower Lawyers