[Velvet]

Originally Posted by OrangeBlossomBaby

It wasn't just a "computer error." Yes I used that term, yes you're quoting me. I was simplifying it so as to not have to type paragraph upon paragraph of hypotheticals to explain a complicated process that could result in a simple error, that would further result in disastrous outcomes. It was a mis-coding. The computer didn't make a mistake. The input was incorrect. If you've ever worked on a medical billing floor you'd understand how this mistake might be made.

An example: a "yearly checkup" might have several diagnostic codes attached to it. It might be C400, C407, C802, C803, R931 (I'm making those up, they might actually be code for something but I'm pulling them out of my head, not from a coding list). The coder inputs the wrong one. Maybe the routine annual physical is supposed to be C803. But the billing department has been entering it as C802, which might be "specialty yearly checkup for patients with early onset dementia, requiring extra stuff that costs more". Because a yearly checkup - no matter what the code is - doesn't cost the patient anything, the patient will never see a bill for it. But Medicare might see a specialty diagnosis that incurs a surcharge of $270 in addition to the $130 they might be paying for a routine annual physical, which has a different code. They'll pay it, because it's a yearly thing. It won't flag, unless it's noticed that it isn't happening yearly. It also isn't likely to flag when it's a "early onset dementia that costs more" yearly exam, when it's a medical group catering to seniors, since early onset dementia isn't all that uncommon for a group that caters to seniors.

Whoever has been inputting the yearly checkups, has been putting in the wrong ones, over and over again. Medicare's been paying on it, because it really IS a yearly checkup - even though it's the wrong code out of the list of codes for yearly checkups.

It's a mistake. The person entering the code didn't mistype, they miscoded. The Medicare system's accounts payable department never flagged it, because they had no reason to flag it. So it just kept paying out too much.

Until someone in the billing department at TVH brought the incorrect code to their boss's attention.

That's all that happened (though I don't know which code(s) were mis-coded, I was using a hypothetical above). It caused a HUGE financial disaster, but the error itself was simple, and not nefarious.

To take your example of miscoding, say $270 vs $130 for the type of visit. For one year of over billing $90,000,000 they would have had to miscode 642,857 times in order to make such a difference. So each and every person in TV would have to have this “annual checkup” 4 times a year - every year for 4 years - to come up with the magnitude of the error.

Hmmm.