How Much Fraud and Abuse Is There in U.S. Health Care?

[steven johnson]

If Uwe Reinhardt had misgivings about ferreting fraud and abuse out of the health care system, a cornerstone of the Medicare cost savings that will make the president's new system balance it's budget, it may not be tenable.

He is a long time proponent of creating a european-style healthcare system in the US.

http://www.pbs.org/healthcarecrisis/Exprts_intrvw/u_reinhardt.htm

Cynics may doubt the sincerity of these extensive efforts at avoiding fraud and abuse. As someone who has sat through many such audit committee meetings, I know otherwise.

Two troublesome facets of this problem, however, should be recognized by readers.

First, the regulations surrounding the rendering of health care services to the federal government are immensely complex. They seem to be based on the idea that every provider of these services is a latent crook.

A second problem faced by hospital executives is that they have only partial control over the costs they must book and for which they seek to get paid. The bulk of these costs are driven by the clinical decisions of physicians who are affiliated with hospitals and can use the hospital as a free workshop, so to speak.

How Much Fraud and Abuse Is There in U.S. Health Care?

[izquierdista]

1. Tremendous amounts of it

Billions. You pay in and pay in on health insurance premiums, and then the death panels fraudulently deny your claim.

[stray cat]

2. trillions is likely right

[Turbineguy]

3. That's why we should

keep things the way they are. Insurance companies by denying your claim, short-circuit fraud and waste! Of course if you have an honest Doctor and you die, well, that's the way things go! Who said life was fair?

[tinrobot]

4. The fraud isn't on the doctor's side...

It's on the side of the HMOs and health insurance companies.

[bemildred]

5. Way over 50%. nt

[kratos12]

6. Part of the problem is how MM is structured

Example:

A provider or especially a non-provider MM participant (think medical supply or equipment company) can submit a properly filled out CMS forms WITHOUT pre-authorization and they will get paid with only infrequent and incomplete auditing for any fraudulent submissions.


Lets say a criminal starts a medical supply company, the criminal obtains a list of MM recipients and their ID#s, they then send properly filled out billing forms to MM. Medicare automatically pays and then only later (sometimes never) they randomly audit to check and see if the billing was legit. This is why you frequently see stories about providers bilking MM for such large multimillion dollar ripoffs. It's because the fraud goes on for a long time before either MM stumbles across it or somebody complains that the EOB they recieved for the Mackdaddy motorized wheelchair was sent in error.


MM could weed out a TON of fraudulent activity if they simply adopted some common sense methods of verification:

1. Pre-authorization: Having a provider or a equipment salesperson call MM to inform them and obtain approval for Mrs. Marple's new wheelchair would weed out a bunch of shenanigans on the front end, especially if you add a requirement that has the insured verify that they have indeed been prescribed the service or device.

2. Medical supply companies required to have a licensed physician as part owner and thus responsible for any fraudulent activity at the risk of their license.

3. Follow up. A call to the insured to see if they in fact recieved said goods or services.


True, it would cost more up front to staff MM to operate like this, but the cost would pale in comparison to whats currently being ripped off.


Last point. I have a friend who works for an agency that investigates MM fraud, for every dollar they spend on investigation they recover 16.

Think about that, 1 to make 16, it's a friggin no brainer, yet his organization is underfunded AND faces potential budget cuts.

Insanity.

[bemildred]

7. That's part of it. nt