Reporters uncover Calif. chain’s systematic upcoding

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

In a follow-up to their lengthy California Watch investigation into sketchy billing practices at the state’s Prime Healthcare chain, Christina Jewett and Stephen Doig looked at newly released data and found that “Prime Healthcare Services bills Medicare for a variety of unusual ailments – among them a brain disease and a condition causing eyes to bleed – that can generate lucrative payments to the chain.”

For this piece, the reporters reviewed hundreds of pages from five related court cases and talked to a number of former Prime employees who protested the hospital’s billing practices — many of which they say were mandated directly by the company’s owner. Doig and Jewett then returned to the data and found that, as the 14-hospital chain’s leadership pushed providers to bill for a certain lucrative condition, instances of that condition just happened to rise in Prime hospitals.

Jewett and Doig even analyzed medical codes to estimate how much the alleged upcoding could have earned Prime hospitals.

It is not possible to pinpoint how much additional revenue Prime earned when documenting the unusual conditions, because each patient may have numerous diagnoses. But it is clear that conditions reported in outsized rates at Prime hospitals can bring in an additional $3,000 to $7,000, compared with similar but less serious conditions.

Taken together, the report stands out for its deft integration data, court records and interviews into a cohesive investigation.

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