Knowledge base

Outlier Payments Fraud

For particular hospital inpatients that generate extremely high costs (due to patient level of condition and length of stay), Medicare makes additional outlier payments to offset the financial impact to hospitals for these outlier patients. As each given DRG is paid the same base amount (see Diagnosis Related Group in this Glossary) the hospital is provided with additional monies dependent upon the extent of the outlier cases. These payments are based on costs, or charges as adjusted by a hospital’s cost-to charge ratio (CCR). CCR’s affect outlier payment because cost is incorporated into payment calculation for these cases. For outpatients, outlier payments are made for services or procedures with costs that exceed the PPS payment rate for their APC group threefold. The statute sets a limit on projected aggregate outlier payments. Upcoding DRG’s is one way that fraud actors generate increased outlier payments.

    Contact Us

    Contact Us

    The more detailed the response, the more likely it is that we will be able to evaluate and determine if your potential False Claims Act case falls within our case requirements. IF IT DOES, WE WILL RESPOND TO YOU WITHIN 24 HOURS. (Names of potential defendants are not necessary at this point, should you feel more comfortable omitting them.) By law, all communications to us are 100% confidential.

    No. of Employees at the Company?
    Please read the following statement and then click "Send Form":

    Any response to your e-mail will be solely to communicate about our possible representation of you under the qui tam provisions of the False Claims Act. All e-mails submitted to us, whether we take your case or not, are 100% confidential. If we do not respond to your e-mail, then you have communicated information which we cannot address because it appears to fall outside of the False Claims Act or our case requirements.