The US Court of Appeals for the 5th Circuit has affirmed a lower court ruling that exonerates Baylor Scott & White Health in a False Claims Act lawsuit about fraudulent coding to inflate reimbursement.
The lawsuit was brought by the data analytics company Integra Med Analytics, which claimed that BSW used secondary codes to increase revenue for years, according to Revcycle Intelligence. The company said the health system pressured doctors to use higher value codes resulting in $61.8 billion in false claims submitted to Medicare.
Some estimates say that one in three dollars spent in healthcare is fraud, waste, and abuse. When employers and the government are the ones paying for the majority fo healthcare in the United States, there is great incentive to prove and stop fraudulent billing practices.
The appeals court confirms a district court ruling from August 2019 that cleared BSW from any wrongdoing and said Integra didn’t provide enough evidence to prove fraud. “These facts strongly indicate that a legal and ‘obvious alternative explanation’ for the statistical data presented by Integra Med is that Baylor was simply ahead of the healthcare industry at implementing the Medicare reimbursement guidelines supplied by CMS,” the opinion stated.
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