Revealed: How GPs are routinely overcharged by hospitals' 'creative coding'
Exclusive: GPs have prompted an investigation into ‘creative coding' by hospital managers after submitting a dossier of evidence detailing what they claim to be routine misuse of the payment by results system.
Hospital staff are accused of a raft of coding errors that have resulted in practices being overcharged by as much as £30,000 in some cases – with one patient reportedly admitted to hospital every day for three months.
GPs warned the alleged gaming – even where strictly within the rules – was a multimillion-pound drain on CCG finances. It also risks hitting GP pay directly through the quality premium, due to be tied to the ability of CCGs to stay within budget.
An Audit Commission report last month flagged coding within payment by results as a national problem, warning ‘inconsistent treatment descriptions' were ‘affecting patients, skewing management information and wasting NHS funding'.
A dossier of suspicious coding behaviour compiled by Avon LMC provides the most detailed evidence yet of how the problem is draining GP budgets. The LMC has formally complained to the Audit Commission and its PCT, which is investigating several cases with the hospitals concerned. Its motion to next week's LMC conference calls on ministers to ensure ‘any creative coding or accounting by secondary care providers is exposed and dealt with as fraud'.
Dr Simon Bradley, chair of Avon LMC, said there was ‘institutional miscoding': ‘We must not let this go unchallenged. The PCT's failure to address this has been a dereliction of responsibility, costing our health community millions of pounds.'
He said hospital managers had inappropriately coded episodes of care as admissions where patients had received oral iodine and even where paediatricians had been called to delivery suites to examine newborn babies.
He said women attending a maternity unit for cardiotocography monitoring were routinely charged as an admission rather than outpatient appointment: ‘One patient will cost the NHS £30,000 or more because she's going up there for three months having one done every day, and each is being charged as an admission. The PCT said to me: "You have high admissions – you are a badly performing practice." And I told them outpatient procedures were being charged as admissions.'
Another example cited concerned patients attending A&E with chest pain who underwent troponin blood tests. Dr Bradley claimed patients who came back negative were placed in chairs in clinical decision units and charged as admissions, even when a further troponin test at 12 hours also came back negative.
NHS North Bristol Trust initially denied it had received any coding challenges, but later backtracked, and in a joint statement with NHS Bristol admitted it had received complaints. The statement confirmed coding of patients attending for cardiotocography had been questioned by the PCT: ‘Controls have been put in the contract to limit the number of attendances paid for.'
It confirmed coding of patients attending A&E with chest pain had been raised: ‘All patients in CDUs have a bed and a chair. All admissions from A&E to the CDU ward are unplanned and charged as emergencies. This is appropriate.'
Dr Chaand Nagpaul, GPC negotiator, said: ‘These coding errors have a significant impact on commissioning budgets. This is a national problem. The system has built-in perverse incentives.'