Rooting Out Fraud and Abuse: Part 1

August 13, 2009
Jeff Kaplan

The concept of healthcare reform is pointless unless we address fraud and waste. It matters little whether providers are cognizant of the fact they are defrauding or are just financial dullards.

The concept of healthcare reform is pointless unless we address fraud and waste. It matters little whether providers are cognizant of the fact they are defrauding or are just financial dullards. These are white-collar crimes, not crimes of passion, which may make them less obvious. Nevertheless, the costs to society of this form of exploitation is direct and insidious. If the perpetrators knew there would be consequences, I am sure that would be a deterrent.

The Shenanigan's Hit List

1. Primary care practitioners (PCP), performing expensive tests that are usually reserved for the specialist; the kind that eventuate in a referral, anyway.

a. Example, a family practice friend just opened his own practice and bragged about specialized equipment he was going to use, justified by the reimbursement level, alone.

2. Replacement medical equipment. Examples:

a. Compressors with reusable nebulizer when a MDI inhaler (a puffer) + spacer will do just as well.

b. One doctor wrote: "Every so often I need new elastic straps for my CPAP machine. The provider insists on giving me a whole new mask set - and bills MC for well over $100."

3. Impatient patients, self-diagnosing rather than visiting their practitioner, and then using someone else's medications for their "bronchitis." Of course when they need more meds, we hear them saying 'we spilled the medicine,' 'we flushed it by accident,’ etc).

4. Treating the worried-well, which begs for over-testing.

5. Churning visits—an incentive in fee-for-service and when a practitioner needs to feel busy (or loved).

6. When prepaid, paid by capitation or case rate (ie, when paid prospectively) and when not at risk for referrals, dumping or being inaccessible, it is easy to refer, dump or defer care.

7. "Who really needs psychoanalysis to the point that others including tax payers should pay? Many psychological practitioners, we would agree overtreat and overcharge, but how can the government oversee that? Have lawyers read all the psych notes?"

a. "Sometimes yes. We need more audits of psych records. A lot more! But at the least the records should be made available to the patient. The ironic thing about some of our colleagues in the mental health field is that many seriously think privacy means keeping the patient’s records from the patient. They have turned privacy upside down and made their own privacy or propensity to act irrationally more important then the patient’s informed consent."

b. "If the patient had access to their records, they could begin to determine the substance and value of their own care. I maintain more than half of that care may be unnecessary, unhelpful or void of scientific foundation."

8. "Some practitioners will concoct a diagnosis or pick a more serious one so that insurance will pay, allow more treatments, or pay more for higher complexity."

From: Meyer S.

9. [] "Some will bill for phone calls as if that care was rendered in the office." Example: "A patient is forced to wait too long in MD’s office; the patient tells the reception desk that he is leaving and that “his time is also important.” He gets an apologetic phone call from MD later that evening, discusses his case for 2 minutes over the phone. Three days later, patient gets a bill for the office copay. (Also, what will happen when E-mail communication between MD and patients becomes popular?)"

10. "There's the drive by—when home visits are involved you stop in for a couple of minutes and bill for an hour."

11. "The big net—you visit an family and bill for each person individually."

12. "You bill for your time—when a patient cancels or does not show (which is common with Medicaid patients), the providers bills as if s/he had seen the patient."

13. In the setting of first dollar coverage (ie, when there's little or no cost sharing), getting care that is not needed.

From: Reggie

14. [] "Others will waive co-payments, not only in cases of hardship, but routinely. That way, since no money comes out of the patient’s pocket, they are more inclined to accept treatments that they did not need or even want, were there cost sharing."

15. Quackery like homeopathy, chiropractors who treat organic diseases with vitamins and spinal adjustments, naturalists and phrenologists.

16. Specialists doing what I do (I'm a pediatrician), getting 4X the amount that I can bill for the same procedure and outcome.

17. Insurance companies forcing me to hire 2 additional staff for our 4-person group just the jump their bureaucratic hurdles, be pout on hold interminably and try to guess under which cup is the prize. (See references)

18. Inertia in tort reform.

19. Writing "Brand Medically Necessary" over bio-equivalent and palatable generics.

20. Antibiotics for truly acute, uncomplicated bronchitis, colds, nasopharyngitis and most ear infection.

21. Paying for an ER visit, but refusing to cover an after hours visit to the PCP's office.

22. Paying for an ER but not for the PCP's office to treat a patient whose insurance they do not ordinarily accept.

23. Routinely write off co-pays as an inducement to use a particular provider.

24. Split a procedure done on one day into two parts, and bill them on two separate days.

25. Bill each patient as a new patient, every time they change insurance, even if they were last seen in less than 3 years.

26. Create a PC that employs non-par physicians, and then refer your patients to these non-par docs (works best with anesthesiology in an office based surgery situation).

27. When performing procedures in your office, bill under a different company name and tax ID, as a facility in addition to the physician fee.

28. When you add technology into the office, use any Dx that will get it paid, even if it does not describe the reason for the procedure.

29. You have to do an exam for which you cannot be paid (say it is required by Medicaid or Medicare or you did an exam recently), so you find a medical problem—sinus variation = "arrhythmia," trivial fluid in the middle ear space—"SOM," "actinic keratosis," rule out "pharyngitis," etc.—and list that as the reason for the visit.

30. "Up code" from ignorance or arrogance. (“I don’t know anything about coding, I let my biller do it”, "I don’t know why they have a problem with my coding, I only use one code”, Our billing company said that we could make more money if we added that code to each office visit.”)

31. The red herrings of medicine: this often comes from testing (or imaging) before evaluating the patient, taking a history or doing an examination.

32. Perform services during the post-surgical global period and bill them as new services.

33. Unbundle, unbundle, unbundle. [Breaking down a procedure into its component parts for the purpose of increasing reimbursement.]

34. Using "midlevel practitioners" (eg, midwives, NPs, Pas, etc), but billing as a MD/DO.

35. Bill Physical Therapy as an MD rather than as physical therapist.

36. Bill individual services for group session and bill individual services as provided to a complete family.

37. You are an out of network practitioner, and you therefore write off the patient portion of the claim, but you do not disclose this fact; that way you get 80% of the allowable, while you should only be getting 80% of the patient's actual liability.

38. Hospital — admit “on paper” every 2-3 years, Medicare patients in the community. If you don’t bill out the patient portion, who is going to know?

39. Provide scripts for family and friends of the covered patient, in the covered patient’s name, to get in on the covered patient’s health benefits.

40. Use sisters ID, uses sisters kid’s IDs for your kids.

41. Provide scripts and refills for “lost” scripts without controls, allowing for the drugs to be re-sold.

42. Add a little something extra: provide unnecessary services; perform and bill for more lab tests, more imaging, etc, than is originally ordered. Order large numbers of ancillary tests. (eg, blood, Doppler, MRI) to be performed by entities in which you have a financial interest or who “rent” space or otherwise pay you based in part on referrals—a violation of the Stark Laws.

43. Posting a policy on your web site and implementing it even though that policy is contrary to state regulation, and it reduces payments to physicians.

44. Deny physicians' bills associated with a denied hospitalization (OK), but if the hospital appeals, they don’t automatically re-process the physician’s bills for payment; instead, they let/make the physician appeal, and if the appeal form the physician is received before the hospital appeal, they deny it, and ignore it, even if the hospital appeals successfully.

45. Pay less than the allowable fee schedule, making the physician choose between the added cost of filing an appeal and just letting it go (knowing that most physicians do not audit their payments from health plans).

46. Send recovery letters for "alleged” overpayments, saying something to the effect that if the state regulations preclude this recovery, 'Just because we don’t have the right to off-set a recovery, does not mean we can’t ask for the money back—After all physicians are expected to know their state’s regulations.' And, if they do object, re-appealing is the doc's headache, anyway.

47. Eligibility confirmation (and rescission) is the biggest fraud perpetrated by health plans — first, confirming eligibility is no guarantee of coverage; second, health plans allow employers to lag, advising them late of employee terminations, while not promptly updating their eligibility screens. Nor do they advise physicians when they do obtain that information; they wait until they farm out the recovery activity months latter.

48. Health plans re-coding the Dx or CPT codes and paying on the altered billing data.

49. Misleading information on Payer eligibility screens — for example, "HMO" Plan with United refers to their Medicaid product. Freedom/Lbty means Liberty product’s freedom plan (they will deny the claim if the physician is actually in the Freedom Product).

50. Health plans posting policies with retro-active effective dates in fine print.

51. Health plans claiming that the physicians are tied to ‘affiliates,” but then provide no assurances on the accuracy of eligibility or guarantee of coverage.

52. Deemers — send out letters requiring objection letter to be mail back, otherwise the physician is deemed (a default position) to have agreed to be part of a new product or plan at a lower or undisclosed reimbursement rate.

53. Profess authority that does not exist: You can’t require credit cards to guarantee payment? — Yes you can. You can’t discharge a patient from you practice without 90 days notice? Yes you can.

54. Continue to request medical records on patients for whom you have already requested same since it is easier than keeping track of what you have been sent.

55. Hire an outside firm to request records on Medicare patients, have non-treating non-physicians review and identify Dx’s that more accurately reflect severity of illness than what the practitioner had identified. Use this information to file an appeal for better reimbursement from Medicare on that basis. Note: this will not be construed as the submission of a false claim.

56. Simplify your life by using just one code. If you have an academic appointment all your office visits must be level 5, after all, shouldn’t you get paid more for your academic prowess because you only see the most difficult and sickest patients. And using one code will save you the time to learn the documentation requirements of those different levels.

57. Delegate all billing responsibility to your office staff. Never ask what they are doing, never have their activities reviewed by an outside professional (accounts, Billing experts) let them know that all you care about is the bottom-line.

58. Hire a billing service to handle all your billing. Pay them on a percentage basis and never ask what they are doing, never have the activities reviewed by an outside professional. Use a billing service with a track record of substantial increases in recoveries in every office in which it has worked. And if they advise you to add codes to your billing, do so; it brings in more money.

59. Bill for services performed in a hospital by residents. After all, you probably talked to them about the case at some point, even if your name is not on the chart.

60. Bill for hospital or nursing home visits when you have made no entry on the patient’s chart. Or, better yet, bill your in hospital patient on a routine system (eg, 5 days out of 7) without actual records for the patient visits.

61. Sign order, prescriptions, or certificates of medical necessity for patient you have not seen recently. The request probably would not have come to your office unless the patient really needs it.

62. Bill for technical services performed by “employees” who “work” for you whenever you call their company. Or let a non-physicians use your number to bill for services “performed” under your supervision.”

63. Ignore complaints from your patients about bills. (After all, it’s not their money.) Just tell have your secretary tell them their insurance will pay for it, and you’ll write off the balance.

64. Write whatever the Medicare Program or the insurer needs to hear to pay the bill. Nothing is ever routine or a checkup.

Want to add your pet peeves? (Feel free to contribute at the end of this section, noting this is a two-part blog).

#7 is from Fredrick H. (MD, PhD, JD)

#7a,b 8-12, 14 are from Reggie J (MH, PhD)

# 23-65 are from Gilbert R, Exec Dir, large, Academic PPO



"Physicians have long expressed dissatisfaction with the time they and their staffs spend interacting with health plans. However, little information exists about the extent of these interactions. We conducted a national survey on this subject of physicians and practice administrators. Physicians reported spending three hours weekly interacting with plans; nursing and clerical staff spent much larger amounts of time. When time is converted to dollars, we estimate that the national time cost to practices of interactions with plans is at least $23 billion to $31 billion each year."

"What Does It Cost Physicians Practices To Interact With Health Insurance Plans?" [Robert Wood Johnson study] Health Affairs, published online May 14, 2009;28(4):w533-w543].

The administrative burden to practice medicine in th US is huge with physicians, on average, spending nearly three weeks a year; nursing staff, more than 23 weeks/doc/yr; clerical staff 44 week/doc/yr on these activities and interacting the health plans. Also, more that ¾ of the survey respondents said these costs have increased over the past two years.

Billing and insurance-related consume an average of 14% of medical group revenues. In terms of specific activities: there are, on average 2/3rds full-time equivalent (FTE) staff/FTE doc doing nonclinical, billing and insurance functions; clinicians spend more than 35 minutes per day on related tasks. The resultant cost to medical groups is about 10% of operating revenue; including practitioner time, that amounts to at least $85,276 per FTE doc.

"Peering Into The Black Box: Billing and Insurance Activities In a Medical Group." [Robert Wood Johnson study as referenced by the Commonwealth Fund] Health Affairs, May 2009.

Looking only at the prior authorization requirements for medical services, including medical equipment, imaging, and injectable drugs, the prior authorization process is overly complex, inconsistent from major health plan to major HP and lengthy, time consuming and overly detailed. Furthermore, "the penalties associate with prior authorizations are unfair.”

A Study of Prior Authorization/Precertification of Physicians Services as Required by Georgia’s Six Major Health Plans. [Medical Association of Georgia study] See: