Wednesday, March 5, 2008

Medicare Fraud - Or Just a Mistake?

I hate waste and fraud as much as the next guy but are "Medicare coding mistakes" really the most pressing activity for our government to go after? Private audit companies, hired by Medicare, will begin scouring mountains of medical records in doctors' offices and hospitals to see if health care providers made a mistake in coding and billing Medicare. Intent to fraudulently bill does not need to be proven...just the fact that the wrong code was used is enough for the Feds to recoup enormous fines. These "recovery audit contractors" will keep 20% of the over payments...quite an incentive to look at every code and be a Monday morning quarterback.

Just to put it in perspective, there are 1.2 billion Medicare claims filed each year and during the first 2 1/2 years of the program in Florida, California and New York (big Medicare states) the error rate was less than 0.2%. Some errors are obvious, such as billing for more than one colonoscopy in a day. But some are just whether a patient has the correct diagnosis to qualify for being admitted or being sent to a rehab facility. The patient already received the medical service or hospital care. If the code for diabetes was switched to heart failure, does it really mean fraud occurred?

Have you ever tried to appeal or fight the government on taxes or parking tickets or anything where you get hung up in bureaucracy? It costs about $2000 to appeal each claim audit, not to mention the personnel costs. Many providers just don't appeal because it is not worth it.

I'm all for ferreting out Medicare and Medicaid fraud. It should be easy to find these clinics I read about, that cruise poor neighborhoods for patients and then do millions of dollars of unneeded tests on them. I say throw the book at 'em.

But coding mistakes (when there are tens of thousands of codes that change constantly) and gray areas of clinical judgment can be legitimate Medicare expenses that do not warrant repayment.

Couldn't we start investigating Haliburton and it's subsidiaries and try and find out where billions of Iraq reconstruction dollars have gone? Now that would be money well spent.


TBTAM said...

They get to keep 20% - sounds like a conflict of interest if you ask me.

Who's auditing them?

Anonymous said...

Of course a doctor is not going to be in support of an audit.

By the way, the Medicare program has a self-admited error rate in excess of 10% according to Centers for Medicare and Medicaid Services, Improper Medicare Fee-For-Service Payments Report, (Baltimore, MD: November 2005).

If you don't think the governement should be looking to curtail wasteful spending, then I have a beautiful island I can sell you for a real bargain.

Toni Brayer MD said...

Anon: I do believe wasteful spending should be curtailed. I do not believe private contractors with large incentives to find coding errors should be unleashed on providers as a method of uncovering fraud and waste. The coding requirements and Medicare regulations are wasteful enough. Sending in auditors drives up health care costs.

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