$6M in Upcoded Claims Investigated at Houston Hospital

A Houston hospital was accused of upcoding, a fraudulent practice that harms patient confidence and inflates costs. In a recent case that underscores the importance of accurate medical billing practices, Memorial Herman Health System (MHHS) in Texas has agreed to pay $6.4 million for allegedly violating the Civil Monetary Penalties Law. The Office of Inspector General (OIG) found that Memorial Herman Health System improperly submitted claims, specifically by automatically appending certain Evaluation and Management (E/M) codes and modifiers to medical services. The overused code was 99201 or G0453.


The allegations against Memorial Herman highlight the potential pitfalls of improper medical coding, which can lead to fraudulent billing practices. In this case, Memorial Herman was accused of automatically appending E/M codes to preoperative assessments performed by nurses, as well as adding modifier 25 to E/M services billed on the same day as surgical procedures.


Coding inaccuracies and fraudulent practices not only inflate healthcare costs but also jeopardize patient care and trust in the healthcare system. Insiders such as nurses and coding coordinators can be valuable whistleblowers that help put an end to fraudulent conduct.


At our law firm, we are committed to promoting transparency and accountability within the healthcare industry. If you have information about fraudulent billing practices or coding errors, we encourage you to contact us. Your actions can help protect patients and uphold the integrity of our healthcare system.


The full report is here: https://oig.hhs.gov/fraud/enforcement/memorial-herman-health-system-agreed-to-pay-64-million-for-allegedly-violating-the-civil-monetary-penalties-law-by-submitting-upcoded-evaluation-and-management-claims/