Healthcare and Medicare Fraud

It is very important that the US healthcare system become less conflictual and more "win/win" for the issues we have today to ever be resolved.

I often hear how horrible the insurance companies are, and there may be many times when the stories are right.  I can also say that spending a week or two reviewing the medical bills submitted to carriers will change any person's perspective on the situation forever.

The federal government is trying to crack down on the pure fraud in Medicare, and that gets the most press, but the same issues apply to everyone involved with healthcare. 

When Rising is reviewing medical bills for our clients, we will occasionally find providers that do not exist when we call them. We will sometimes get what is obviously a cell phone with non-office noise in the background when calling a provider's office.   Addresses that are not medical facilities will be on bills.  Providers that have lost their license to practice will be listed as the treating physician.  The list goes on and on.

Once, there was a provider who billed for more hours in physician services than there are in a day. That assumes this provider’s daily schedule was solely seeing our client’s insured patients and the provider worked more than 24 hours that day - statistically not likely.  Some things really get to me, and this was one of those things.  

A couple of us drove to the doctor's office and staked it out for a day.  No patient or provider went into the building for the whole day.  Wow - what bad luck.  The “busiest” office and the “busiest” physician I have ever come across and we saw it on a day when nothing was happening.  Later, we scheduled a visit at the facility.  When we looked around the office, there was still almost nobody there.  They didn't even have the equipment for the majority of the services they had been charging our clients for. There were, however, a ton of forms offering free consultations to people who had been injured at work or in an auto accident.  We took a bunch and we mailed them in whenever one of our clients got a new patient bill from this facility.  We eventually stopped receiving their bills.  For all I know, they're still billing other carriers, just not the ones that work with Rising.

In this day and age, it's critical that systems are in place to prevent fraud and overpayment.  I am horrified by the stories I hear at Medicare and other large carriers.  It's costing all of us in increased healthcare costs and taxes.  A lot of this fraud would be easy to resolve forever with very basic controls.  It does a disservice to the patients, good providers and the health of insurance payers to not have good controls in place so that payments are only made for treatment that was actually done.