Rooting Out Fraud and Abuse: Part 2

August 21, 2009
Jeff Kaplan

Healthcare is already being rationed. Major healthcare decisions are already being made every day by insurance companies, not doctors.

From: Ellen [She investigates fraud in billing records (Medicaid)]

Sent: Friday, July 03, 2009 5:33 AM

I read your [original] list of 22 possible fraud and abuse scenarios, replete with behavioral medicine/mental health examples. I can comment: my job to look at psych records, and anyone else's records that we believe may be defrauding the State.

What we are looking for is:

1. Billing for services that are outside of the norm for one's specialty in the area of expertise. (That is the first criteria.)

2. Then we order records to verify that what the practitioner wrote on the encounter record actually matches what they billed (coded).

On an official level, we couldn't care less what the patient is talking about, what their Dx is, or what modality the physician has decided to use in Tx -- it is not our charge to evaluate the quality of the physician, or the nuttiness of the patient.

However, if I see something that is really egregious, I hand it off to a group of physicians that evaluate the circumstances, the documentation and ultimately the quality of the care.

From: Fredrick

Sent: Friday, July 03, 2009 12:08 PM

Aha! Finally, someone who REALLY knows!

I suspect fraud isn't aggressively pursued because it is to the financial advantage of the insurers who administer Medicaid to have the costs high.

Anyway, in terms of the cost of care and what we get out of it, we don't stack up well against other Organization for Economic Cooperation and Development (OECD) countries [Ref: See Bartlett, B. Forbes, July 2, 2009]. How much does fraud and abuse contribute to that disparity? For instance, what's your impression as to the prevalence of fraud in Medicaid billing in general and in psych records in particular?

From: Ellen

Sent: July 3, 2009 2:59:45 PM EDT

If we had single payer, then cheating would be a felony. To BCBS, Wellpoint, Aetna, Cigna - most cases never get referred to the OIG because all the company wants is the money back; the fraud continues, regardless. (That is, unless it is MASSIVE Medicare Fraud, or semi-massive Medicaid fraud.)

From: Gilbert R.

Date: July 3, 2009 3:39:27 PM EDT

Plans are currently obligated in NY to turn providers over to the AG for suspicion of fraud, but weasel out by signing non-disclosure agreements and then calling everything a 'billing error.'

From: Michelle M.

Sent: Thursday, July 02, 2009 12:55 PM

We have an open, free market healthcare system, don't we? I just wanted some comparative information, so I asked the four doctors our family uses (three different clinics) for a list of what they charge for services. How much is a visit to the doctor or a nurse (for the latter is what we often get) for blood pressure readings, weight checks, lab processing and for additional services. None has a price list I can use to compare services and costs. Isn't that something?

The people at the three clinics I called, asked who is my insurance company? If they are participating (par), we continue. Then they gratuitously assure me: 'what we charge is covered by your insurance, so don't worry.' I simply had to shell out for the co-pay and it shouldn't concern me what the insurance company pays the doctor, etc.

Help me understand this obfuscation—I used to sell expensive enterprise application software (EAS) to Fortune 100 companies. We had five competitors and everyone knew the prices. In fact Boeing refused to buy my software unless I told them what it cost. I should have told the VP: "Listen, the stockholders pay for the software; it doesn’t come out of your hide, so just give me a P.O. and I’ll fill in the prices."

This is not a market-based system wherein a competitive marketplace insures fair pricing. It is socialism for the rich, the greedy and powerful. I have a healthcare insurance provider that pays their CEO $25,000 per our, $200,000 per day, one million per week, to do nothing that helps me. I could to go to a provider that pays the CEO less, but I get my insurance through my wife’s company (I am retired). Her company provides no choice of insurance companies, so I am stuck 'supporting' that greed.

Our healthcare system has no financial accountability—not by patients, not by physicians and not by the big mucky mucks in the corner office on the 36th floor.

In Letters to the Editor (the New York Times, July 3, 2009) Vicki Riba Koestler says: "As illustrated in 'Insured but Unprotected, and Driven Bankrupt by Health Crises' (front page, July 1), health insurance is often a meaningless product in that it offers neither health care nor security.

Actually, I don’t understand why America is still talking about providing all its people with health insurance, as opposed to providing them with health care. Health care is a necessity of life, like education and food."

And Dzung Vo adds, "As a physician, I am having a lot of trouble understanding the talk about terms like “managed care” and “rationing” being used to scare off support for fundamental change in our healthcare system.

Healthcare is already being rationed. Major healthcare decisions are already being made every day by insurance companies, not doctors.

Any health care provider can tell you about the inordinate amount of time and energy we spend fighting for our patients to get the care that they need and deserve. This results in less physician time with patients, reduced quality of care, increased health care costs for everyone, and—no accident here—increased profits for insurance companies’ executives and shareholders."