Shedding light on upcoding in the ER

Joanne Kenen

About Joanne Kenen

Joanne Kenen, (@JoanneKenen) the health editor at Politico, is AHCJ’s topic leader on health reform and curates related material at healthjournalism.org. She welcomes questions and suggestions on health reform resources and tip sheets at joanne@healthjournalism.org. Follow her on Facebook.

Photo: Micheal J via Flickr

The Houston Chronicle’s Jenny Deam delved into emergency room billing – hospital facility fees as well as “upcoding,” which means categorizing relatively minor conditions as serious or even life-threatening ailments and charging a lot for them.

It raises costs to both the patient and the insurer.

Deam knew there was a story because ER spending was going up, even though the number of patients was holding steady.  Not everyone could suddenly be that much sicker.

“My suspicion,” Deam wrote, “was that the severity of the patient conditions was being manipulated, or ‘upcoded,’ and perhaps that excessive tests were being ordered to justify the higher code – which meant more revenue to the hospital. But could I prove it?”

Jenny Deam

She did.

Using a variety of outreach techniques, Deam collected bills, followed up with patients who were willing to go on the record and share their actual itemized hospital statements, two of which are included in her new How I Did It piece for AHCJ.

She explained, for instance, how fluid in the ears related to a sinus infection or how a simple tetanus shot could lead to enormous bills. Her piece is a good guide to understanding what ERs in your community are doing (even if, unlike Texas, there are no free-standing ERs.) and shedding light on their practices.

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