Looking the Other Way

Recently, federal agents have uncovered what is claimed to be “the single largest fraud orchestrated by one doctor in the history of the Health Care Fraud Prevention & Enforcement Action Team (HEAT) and the Medicare Strike Force operations.” (1) Although there are other accomplices charged in this mammoth scheme, it is reported that a single physician in Texas wrote or authorized prescription benefits for over 10,000 patients for home health care services that they didn’t need or receive. Using cash payments, food stamps and free groceries as enticements, the accused were able to sign up individuals for home health care services that committed fraud against the Medicare and Medicaid programs for a reported $375 million from January 2006 through November 2011.

This is not an isolated incident. Federal agents recently arrested 10 people (3 medical doctors, an osteopath and a chiropractor) who operated out of two medical clinics in Flushing, New York. They have been charged with running Medicare fraud schemes that have bilked the government out of $95 million. (2)

Estimates put the dollars lost to fraud at $60 billion last year alone. Officials report fraud involves everything from marketing schemes by pharmaceutical companies enticing doctors to prescribe drugs for unauthorized uses, to selling motorized wheelchairs to people who don’t need them. (3) Since the Medicare Fraud Strike Force came into existence in 2007, the agency has charged over 1,190 individuals in cases worth $3.6 billion. It has only been recently that the Department of Health and Human Services (HHS) has been able upgrade its data evaluation process that made the discoveries of the above two schemes possible.

These egregious acts may be isolated, but more than likely they are just the tip of the iceberg. However, they do bring awareness that the current system of monitoring for fraud is broken. It is also probable that simply using better computer programs alone to ferret out the offenders is not going to ameliorate all these problems.

One wonders if other members of the medical community either suspected or knew that these schemes were occurring, especially with the enormity of the charges that were being generated. If they did, why did they not inform the proper authorities of their suspicion? Is it that they didn’t want to get involved for fear of repercussions? Or is it similar to the often-told story of New Yorkers who had become so accustomed to the local street crime in their city they just ‘looked the other way’? Fortunately, several local administrations later, the crime rate in New York City is now better. But with these recent examples, one has to question if the same is occurring in the delivery of health care.

These two stories made headlines, but what gets glossed over is the so-called ‘nickel-dime’ charges that occur daily all across the country. The cataract surgeries that didn’t qualify under the standard Medicare guidelines. The back surgeries that could have been avoided with more time to ‘cool-off.’ The CTs or the MRIs that would have not been ordered if the treatment of ‘observation’ had just been tried first. Unfortunately, there are many more examples.

A patient arrived at my office recently. Her chief complaint was that she wanted surgery for her cataracts. After a careful examination, I determined her cataracts were not advanced enough that she needed, or qualified for surgery under the specific Medicare guidelines. Obviously disappointed, she responded to my answer with, “doctor, all my friends have already had theirs removed and their vision was not as bad as mine.” She then continued with a profound observation about the medical profession, “we all know how it works.”

That patient and her friends think committing Medicare fraud is a game and their doctors should be complicit. Otherwise many will look elsewhere. This way of thinking is the antithesis of what physicians have stood for since the Oath of Hippocrates was first penned. It is also a sad commentary on the perception of today’s medical profession.

A recent Internet video revealed a grandmother, who was knowingly, but secretly, being taped as she answered questions about her health. The questions were posed by a representative of one of the health care clinics implicated in a recent HEAT team sting. Later the rouse was revealed and the representative’s written answers exposed.  There was no correlation between them and what the grandmother had answered.

When physicians order tests and perform surgeries that they know don’t qualify under the payer’s guidelines or could be done in a less costly and invasive way, they are not just ‘bending the rules.’ They are committing fraud against the payer, against their patients and against their profession. Most important they are committing fraud against what they represent as physicians.

Additionally, those who sit idly by could be considered just as complicit. Maybe one of the reasons these fraudulent acts continue almost unabated is that the medical community has not been willing to expose them without fear of reprisal.

A spokesman for the Texas State Board of Medical Examiners (TSBME) revealed that state law protects the confidentiality of any party who brings complaints of inappropriate physician activity to their attention.  By state law also, they are not allowed to investigate or act on any matters that are sent to them anonymously. Allegations that are more wide-sweeping, according to the TSBME spokesman, will be turned over to the proper authorities for any further investigation. (4)

The medical community must take on more responsibility to police itself. Otherwise, somebody’s grandmother will do it for them!

(1)    Statement by Deputy U. S. Attorney James Cole

(2)    http://cityroom.blogs.nytimes.com/2011/11/02/12-are-charged-in-medicare-fraud-schemes-said-to-cost-95-million/

(3)    http://www.denverpost.com/news/ci_20062017?source=rss

(4)    Interview with a spokesman for the Texas State Board of Medical Examiners

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