Friday, December 15, 2017
Opinion

Column: Lessons in rooting out Medicare fraud

Last month a Venice dermatologist paid $26.1 million as a settlement to the United States following a nine-year civil and criminal investigation. The physician was alleged to have committed Medicare fraud, including kickbacks and performing medically unnecessary surgical procedures.

This is the largest fraud settlement amount paid by any single physician in Florida, and it may be the largest amount paid nationally.

Here's the key to this case: The fraud was uncovered because another physician observed the problem and put his career and future on the line by reporting the behaviors he had seen to the U.S. authorities. I represented this physician over the course of those nine years, and I believe there are key lessons to be learned from this case.

The first lesson is for the professionals: Doctors can stop fraud, as can administrators and office managers — anyone involved in billing. We cannot allow a culture that sees fraud and waste as normal practice in this complex system.

I don't know any physician who goes into practice with the intent of committing fraud. But the complexities of billing and keeping track of dozens of payers, added to cost-cutting by insurance companies and Medicare, create the perceived need for billing staff in providers' offices to look for ways to optimize reimbursements. And sometimes that means doing "creative" things.

Under pressure, there's a temptation to agree to a business relationship with somebody who will make your business more profitable — somebody who will kick back a part of what they get paid in exchange for sending them cases, for example. In fact, kickbacks outside of health care are common and legal. Incentives are part of the nonhealth marketplace.

But in health care, these practices encourage care providers to perform services that may not be medically necessary — or even to claim that they were provided when they were not. For some, it becomes the rule, rather than the exception. And after years of doing this, there is a certain indignation that bad players express when they get caught.

Doctors can and should blow the whistle on unnecessary treatments and inflated costs. In this case, a doctor did the right thing.

The second lesson is for all of us: Fraud costs us all, as taxpayers and as patients. We should watch for it.

All of us, as patients, health care workers, and politicians, should be concerned about fraud and abuse. It is killing the health care economy and it can hurt and kill patients when unnecessary care is provided.

Part of the solution is what Thomas Jefferson called "constant vigilance." Be good consumers and concerned citizens. Ask questions, especially about the care you receive. Look at bills and reimbursement forms to be certain that the things that were charged were things that were done — and don't hesitate to ask questions about why things are being done in the first place.

The third lesson is for our elected officials: We need Medicare and Medicaid. We also need to make it efficient. If we can improve these government programs, we can improve all of health care.

The kind of fraud and abuse that occurred in the recent Florida case was practiced over the course of many years, and is the exception rather than the rule.

We all want health care that is affordable and safer. The war against fraud can help sharpen our focus on those improvements in our health care system. Good heath care requires a partnership between patients and providers, along with responsible behavior by both.

Medicare fraud and abuse has been part of the reason for health cost increases and health insurance costs rising every year. It is also a source of real risks and harm as a result of medically unnecessary services that are often performed to pad bills.

The Affordable Care Act ("Obamacare") contains significant increases in federal antifraud initiatives because of the scope of bad actions by bad actors in the $3 trillion health care marketplace. The secretary of Health and Human Services noted, after this case settled, that for every dollar spent to prosecute Medicare fraud, the federal government recovers $7 from the bad players.

The lessons I learned are simply this: Better, safer care depends on all us. We should praise physicians — and indeed elected officials — who are working to make the payment systems work efficiently. As patients, we should join them. It is our health. It is our money. It is our responsibility.

Jay Wolfson is a health attorney and professor of public health and medicine at USF Health. He wrote this exclusively for the Tampa Bay Times.

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