Healing Health Care: Dealing with health care fraud head-on

Massive health care fraud exists due to the ease of accomplishing it, combined with poor oversight.

Two examples of this are:

1. In 2004, the Centers for Medicare & Medicaid Services (CMS) proudly reported to Congress that it had lowered the rate of widespread fraud in durable medical equipment (DME) to 7.5 percent. The Office of the Inspector General reviewed the study and made the amazing discovery that CMS had instructed the outside auditor not to look at doctors’ notes, but only at the notes sent in by the actual DME provider. Self-reporting of criminal activity doesn’t work too well. They did a new audit and found that, in fact, one in three of the claims were fraudulent.

2. In 2006, the Government Accountability Office reported to Congress that a review of the anti-fraud programs in Medicare’s prescription drug providers showed that only two of five randomly chosen providers had evidence they complied with the requirement to have fraud control procedures in place. The other three had not done anything. They found that CMS had simply asked the plans to fill out a self-assessment form, rather than CMS doing on-site audits.

CMS responded to harsh criticism by showing that they had only $700 million to try to stamp out billions of dollars of fraud. The government had indeed refused to adequately fund this activity for years. Both the government agency and congress had failed us.

What can be done?

We must demand from our representatives that they show us they understand this massive problem and have put it at the front of their priority list. And be willing to show us the specifics and results of anti-fraud programs — with dollar signs attached.

An equally important factor is patient involvement.

The best thing to happen in this area is the Internet. No longer does a patient have to be in the dark. If a doctor wants to do something that you really don’t understand, research it (or have a friend do it). There are excellent, non-biased Web sites for this. WebMD.com is easy to understand and provides invaluable information. It would take a few minutes of reviewing such a site to determine whether you need a recommended test, especially if the test is done in the doctor’s office. Ask questions. Ask if a screening test is recommended by the U.S. Preventative Service Task Force for people with your history. Ask, “What if the test is abnormal?” What would have to be done next? Many people have experienced an abnormal screening lab test only to be told by the person ordering the test, “Don’t worry about it, it doesn’t mean anything.” Check lab and X-ray reports for yourself; you own them.

Do you need this test?

Many procedures are questionable and simply represent abuse of the system.

Non-recommended screening tests such as “stroke screening” without the patient having risk, 24-hour heart monitoring, heavy metal blood tests, breath analysis, whole body CT for cancer screening, etc., are usually done for financial reasons. A recent ad for an office-based Holter monitor (24-hour heart rhythm recording device) claimed a doctor could easily pay for it in less than 2 months. And they’ll show him how to bill for maximum reimbursement

Check your bill

Then comes billing. Always look at your EOB (explanation of benefits). If it seems unreasonable, ask your insurer for an explanation of the billing codes. If you find the doctor billed for a level of service that seems out of proportion to the service rendered, such as a two-minute visit with little more than a greeting, a new prescription and telling you to return in four weeks, discuss it with him. If he doesn’t want to discuss it or blows you off, then change doctors — but only after you’ve complained to your insurer.

This is especially true for in-office minor procedures. If you see high charges for simple procedures, such as trigger point injections, freezing off a small skin lesion, etc., question the bill.

It is only when unscrupulous providers (the minority who cost our system greatly) become aware that patients are involved in their health care dollars that they will think twice.

If we don’t get involved, then the great American philosopher, Walt Kelly, will be right: “We have met the enemy and he is us.”

Charles Barta retired to Green Valley this summer after 10 years as a medical director for several health care insurers in Denver, including Colorado Access, the non-profit Medicaid HMO, Community HealthPlan of the Rockies, United Healthcare and Anthem Blue Cross. Before that, he was physician-in-charge of Kaiser Permanente of Colorado. He also was a private internist in Las Cruces, N.M. He had previously held a management position in the Medical Systems Division of Pfizer. He can be reached at Cbar52@aol.com