Prime Healthcare Billing Processes Under Question as 25% of Medicare Patients are Showing Malnutrition- Profit Algorithms?

This is something worth reading as we are all focusing on getting correct billing information entered today and with potential fraud in the high beams today as a focus.  Interestingly enough Kwashiorkor is being indicated highly on a large number of patients, malnutrition.  Prime has hospitals right in my back yard here in Huntington Beach and this is not a demographic area to where this would seem to be an issue as it just is not prevalent.  There’s not a lack of food here and the OC has a huge focus on healthy foods.  The analysis done here looks at the over all averages and compares the data from Prime to the rest and the Orange County Register provided some visuals here as to what it looks like, startling by comparison.  When  Huntington Beach Hospital shows the highest numbers of malnutritioned patients its time to look at the data.

It’s all back to the algorithms!  This is why that word holds center stage at the Medical Quack, learn what they do and how mathematical functions take place for perhaps accurate or maybe desired results, there are both kinds roaming the world out there. 

“The hospital with the highest malnutrition rate for seniors in California was Prime’s Huntington Beach Hospital, which serves a city with a low poverty rate and average income of more than $100,000 per family. The hospital said 39 percent of its Medicare patients were malnourished. “

I”n 2008, hospitals received about $5,300 on average from Medicare for treating a stroke patient, the report says. But if the patient also was diagnosed with malnutrition or any of the hundreds of other ailments that Medicare classifies as a medical complication, the payout was about $6,100 – 15 percent more.”

36 percent of kwashiorkor cases for Medicare occurred at Prime Hospitals so the question arises for investigation for potential upcoding here in order to receive higher compensation from Medicare.  Kwashiorkor is normally a 3rd world disorder so why do we have it documented at such a high rate here?  Again, I live in Huntington Beach and I just don’t see a big number of mal nutritioned citizens here as a consumer walking around.  If stroke victims suffer from malnutrition (kwashiorkor) or other ailment combined at the time of billing the article goes on to say as much as 50 percent more can be compensated.

So who’s making the interpretation here for the billing?  Is this an automated process or are the doctors entering the data, and I think it’s more than likely tied into billing data entry.  As a comparison, with the 39% reported malnutrition rates at Huntington Beach hospital, Hoag a few miles away is at 5.6 percent.  This inquiry began back in October of 2010 and Prime historically has not signed contract with insurance companies and thus so charges their normal and customary fees.

This brings me also back around to other flawed data on the web, Health Grades as when you look and see the ratings, how do some of these same hospitals rank with 5 stars?   You can read my prior posts on hospital and doctor ratings here as I found dead doctors and all kinds of other discrepancies there including listing doctors at hospitals to where they have never set foot.  I stumbled on to this on my own seeing my own former doctor listed who I knew has been dead for almost 8 years.  Here’s the screenshot but they have since cleaned some of this up I am told and the Private equity firm I would guess is hoping in time to cash somewhere along the line.

This is a good case where analytics and business intelligence come in handy to take a look at what is really happening here and are we getting accurate information as consumers.  In researching information for this blog I can’t help but see advertisements galore all over the place on the web with companies touting how they can help hospitals generate more revenue and not miss a penny of due compensation, so this might go a little further into maybe looking at the Health IT vendor possibly.

Healthcare in the US is sadly resembling some care in third worlds at times and let’s hope this is a billing issue and not really the case here, which again I don’t think in Huntington Beach we have that high level of malnutrition occurring.  I’m all about accuracy in data and consumers and the government deserve it.  We also had cities like Buffalo paying premiums on dead employees too for a number of years, so again we need audit trails and accuracy to avoid money being spent where it should be.

This is just one more example and I think we probably stand to see a whole lot more of this type of investigating to continue to get down to the truth of what is happening all throughout healthcare in the US as it’s all revolving around those profit making algorithms, some are accurate and some may not be.  In November of 2010 one more hospital became part of the Prime Network and usually what has occurred is that services that are not profitable go, but the ER rooms get most of the attention as this is where profits can be made.  BD

Redding, near Mount Shasta, and Victorville, in the Mojave Desert, have little in common but an unusual statistic: In each city, a hospital has reported alarming rates of a Third World nutritional disorder among its Medicare patients.

Kwashiorkor – a Ghanaian word for “weaning sickness” – almost exclusively afflicts impoverished children in developing countries, especially during famines, experts say.

But in 2009, Shasta Regional Medical Center in Redding reported that 16.1 percent of its Medicare patients 65 and older suffered from kwashiorkor, according to a California Watch analysis of state health data. That’s 70 times the state average of 0.2 percent. At Desert Valley Hospital in Victorville, the kwashiorkor rate among Medicare patients also was high: 9.1 percent, or about 39 times the state average.

Both hospitals are owned by Prime Healthcare Services, a Southern California chain that specializes in turning around financially troubled hospitals. The chain is the target of state and federal investigations for allegedly overbilling the federal Medicare system by millions of dollars in connection with a reported outbreak of septicemia infections.

Like malnutrition and kwashiorkor, septicemia is among the medical complications that qualify for enhanced Medicare payments, according to federal records.

Kwashiorkor itself is a childhood protein deficiency often associated with “the premature abandonment of breast-feeding,” The Merck Manual medical dictionary says. It’s noted in regions of the developing world where staple foods are low in protein. News coverage of famine in Africa often features images of young kwashiorkor victims with the distended bellies that are a chief symptom of the disease. Other symptoms include swelling of the feet, loss of teeth and hair, and liver problems.