To the medical professional, Medicare Fraud is not a new issue. Yet the statistics in the U.S. are astounding as fraud and abuse occurrences keep mounting because of human error and the medical provider organizations that commit the crimes become more brazen; costing the American taxpayer billions of dollars per year. The following insights will assist health care and hospital administrators from feeding the issue.
The lines can become a bit blurred when defining Medicare “Fraud”. As a medical professional assisting in safeguarding against Medicare Fraud “red flags”, one must realize the terms Fraud and Abuse are two different terms with very separate meanings when it comes to the Federal Government. In short, “Medicare fraud happens when Medicare is billed for services or supplies you never got. Medicare fraud costs Medicare a lot of money each year. Abuse happens when doctors or suppliers don’t follow good medical practices, which leads to unnecessary costs to Medicare, improper payment, or services that aren’t medically necessary.” (Medicare.Gov, “Report Fraud And Abuse”, http://www.medicare.gov/forms-help-and-resources/report-fraud-and-abuse/fraud-and-abuse.html)
“Abuse” is the term used in the Medicare system when human error happens in the procedure room whether it be surgical implements (ie: Sponges) are accidentally sewn up into a patient’s body upon completion of a procedure, or even worse, the wrong body part gets the procedure or the absolute wrong procedure happens all together. After the realization of and the procedure to correct the mistake, the medical providers then submit billing reimbursement requests to the Medicare system for said mistakes.
Many hospitals and medical professionals have implemented pre-operation procedures to safeguard against surgical and procedure mistakes. Kevin Sack points out in his NY Times article, “Medicare Won’t Pay For Medical Errors”, how medical teams are now practicing the philosophy of promotion of health vs. quantity of care; putting systems in place to prevent errors and excess. For example, one doctor interviewed, Dr. Peter Cole, has a “TIME-OUT TOWEL” in his operating room that is placed on top of every table, instrument, piece of equipment, and eventually the patient her/himself that will not be removed until his team concurs on every aspect of the surgical procedure such as identifying the patient and going over their profile, equipment needed for the procedure and the procedure itself, and actually being in agreement about which body part is being worked on as to ensure for example a perfectly good right ankle is not being worked on when it indeed is the left one that needs fixing. It is not until all members of the surgical team are in agreement and concur that the procedure moves forward. Much the same when finishing, the team goes through the checklist to ensure all are in agreement with the closing of the procedure, all the way down to counting sponges and surgical instruments. (Kevin Sack, “Medicare Won’t Pay For Medical Errors“, http://www.nytimes.com/2008/10/01/us/01mistakes.html?pagewanted=1&_r=1, NY Times, September 30th, 2008)
In the meantime, the Centers for Medicare and Medicaid Services is conducting audits to prevent improper billing. The agency is also starting more extensive medical reviews of billing practices that will identify those hospitals or doctors that are billing for much more expensive services than their peers, according to the letter. While not unprecedented, the letter is especially blunt. (Reed Abelson and Julie Cresell, “U.S. Warning to Hospitals on Medicare Bill Abuses “, http://www.nytimes.com/2012/09/25/business/us-warns-hospitals-on-medicare-billing.html, NY Times, September 24th, 2012)