Searching for Waste and Fraud in Health Care? Look Absolutely Anywhere

by francine Hardaway on November 27, 2009

How much of our rising health care costs comes from fraud in the  health care system by players who know how to game it for their own benefit?  Enough to cloud the reform debate, that's for sure. And it can't be pinned on one player; it's up and down the value chain in medical care.

On the one hand, you have the recent 60-Minutes report on drug dealers in Miami who defraud Medicare by opening fake clinics and pharmacies. They get reimbursed for artificial limbs ordered for patients whose IDs they have bought on a black market for Medicare information.

Further up the line you have hospitals who bill Medicare for procedures that could be done in an outpatient setting where they would cost less, or for total care of a patient whose actual care is split between two hospitals, both of whom bill for the entire care. (Go look on the Center for Medicare and Medicaid Services web site for the Recovery Audit Contractor pilot program in which this was discovered.

And then there's the sweetheart deal the insurers got to participate in the Medicare Advantage program, which was started when CMS was afraid not enough providers would participate in Medicare. In Medicare Advantage, all the players get paid more than by regular Medicare for providing the same services. Medicare Advantage is targeted by the cost-cutting initiatives, but here's what the plans said: "many commenters contend that, if rates are reduced, MA organizations will have trouble maintaining their provider networks, because they will have to pay providers less, and will have to raise premiums, increase co-pays and deductibles, especially in rural areas, Puerto Rico, in the case of Special Needs Plans (SNPs), PACE plans, and plans that are in direct competition with cost plans."

Finally, we get to the pharmaceutical companies, where we learn that "by suppressing negative studies, relentlessly pursuing positive trial results, and paying academic researchers to promote their therapy, Merck Schering-Plough has managed to hold onto a $4.6 billion market for a drug that has never been proven to be better than cheaper generics in preventing heart attacks or death. "

That's a pretty shocking allegation from the HealthBeatBlog, where Maggie Mahar, maker of the film "Money-Driven Medicine," does her investigative work. Naomi Freundlich has written a great piece there pointing to the fact that Merck Schering-Plough holds the patents on Vitorin and Zetia, two widely advertised drugs that in studies have proven no more effective than the vitamin niacin and a generic statin, simivastin.

And this doesn't even begin to touch controversial issues like outcomes-based medicine, which might mean fewer mammograms, CT scans, and other procedures that irradiate us often unnecessarily as the doctor either tries to prevent malpractice allegations or perhaps even owns the imaging center.

Everywhere you look there is waste and downright fraud in the health care system, perpetrated by both payers and providers, public and private. I have no doubt that Obama is right that we could fund health care reform by cleaning up the waste, but the lobbyists for the staus quo don't want it cleaned up. They are profiting from waste and fraud, not from legitimate services, IMHO.

Posted via email from Not Really Stealthmode

{ 2 comments… read them below or add one }

RichWojtczak November 30, 2009 at 7:26 pm

Francine, you are absolutely correct — so what can we do about it? I received a billing from a doctor that my daughter (a dependent) visited, only for a refill prescription for asthma medication, since the first was expired. The doctor's office mistakenly billed an old insurance provider, so it bounced and they then billed me — for $185, and she never saw the doctor. I called the doctor's office for an explanation, left a message on their answering machine, and never heard from them until the bill once again arrived in the mail.

I could simply tell them that they billed the wrong company, but that is ridiculous. The charge should never have been that high to begin with, even though they all play the game of charging exhorbitant amounts and accepting the “plan payment”.

Having vented on that part, there is little that I believe I can do to have any impact on this type of situation. These types of charges should never have occurred. My daughter was in the doctor's office for 5 minutes, received the new prescription and left. There was no evaluation or examination.
So, what can I do about it? If I refuse to pay the bill, I will be dinged on my credit report, at minimum. The AMA could care less. The insurance companies have bigger fish to fry.

The easiest thing for me to do is to simply inform the doctor's office of the billing to the wrong insurance company. That is SO wrong.

hardaway November 30, 2009 at 9:04 pm

Yes, and the doctor's office may or may not bill the correct insurance
company. They hate billing third parties.

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