Monday, June 15, 2009

Fraud and Abuse in Medical Care

Lately with the discussion in politics about reforming health care, many have discussed what drives the cost of health care up. It's really simpler than you would think, its fraud, Abuse, and Greed.
Billions and Billions are lost each year with doctors, hospitals and such, using upcoding ( where they do one procedure and charge for a procedure that is more expensive ) Unbundling ( where a service should be included with the main service and it is " picked apart " so that more money can be charge. There is outright total Fraud , one doctor was caught charging for performing cataract surgery, and laser procedures and it was found out that all he had really done was shine a light in patients eyes, they found him guilty of stealing millions that way.

In one case Defendants submitted at least 2,135 false claims to the
Government for payment under Medicare for YAG Capsulotomy
procedures which not medically necessary and for which
Defendants falsely indicated to the patient that the procedure
was needed.
Sometimes the cases show that patients were harmed by these fraudulent doctors , other times, it is just the taxpayers paying for the medicare bills , sometimes it is the insurance companies that pay, driving up the cost of health care, so in EVERY instance, someone is hurt.
This is where individuals come in, they have to turn these people in, report the fraud, you can do it to medicare , or health and human services, or you can file a Qui Tam,, a " false claims act " charge . Under the False Claims Act, the person reporting the fraud , with the proof, can receive a percentage of what is recovered! One doctor who turned in another doctor, received over a million dollars!
You can report it directly to attorney general of your state if you prefer,, below is one case, Taxpayers Against Fraud has some good info and links

Taxpayers Against Fraud

U.S. ex rel. Woods v. Paracelsus Healthcare
Corp., No. 98-4564 (C.D. Cal.)
Marvin Balistocky, M.D.
In May 2001,Marvin H.Balistocky,M.D.agreed
to pay $531,026 to settle allegations that he sub-
mitted false claims to Medicare and Medicaid in
connection with ophthalmological care.
Among other things, the Government claimed
that Dr. Balistocky submitted false claims for
laser surgeries performed as part of post-
cataract removal surgery by indicating that the
surgeries were performed after the ninety day
post-operative period; submitted claims for ser-
vices that were either never rendered or upcod-
ed; and submitted claims for two patient evalu-
ation and management services per patient visit.
In addition, Dr. Balistocky has been charged
with two counts of criminal health care fraud.
Assistant U.S. Attorney Margaret Hutchinson
represented the Government.

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