Tuesday, February 23, 2010

About A Third Of the President's Reform Proposal is Devoted to Attacking Medicare Fraud: Will It Work?

Looking back at its career, the Disease Management Care Blog suspects at some point or another, it could have been accused of having technically committed Medicare fraud. Not intentionally of course, but the intensity of service, the documentation, the modifiers, the "incidental to's" CPTs, DRG's, ICD-9's and whatever else was used by the billing office was a thicket of coding logic that seemed to get more complex with each passing year.

That's because with each passing year, the regulations grew more complex in response to increasing levels of Medicare fraud. The DMCB recalls when the teaching hospitals got slammed, the Tenet imbroglio and HCA's expensive troubles. And it hasn't stopped there, including issues, for example, with 'professional courtesy,' enrollment rules, and lately the dreaded Recovery Audit Contractors. In fact, the DMCB stumbled across a Google function that collects web pages on the topic of Medicare fraud and they number in the hundreds. Like an arms race, the government ratchets up its anti-fraud efforts and still, the miscreants find new ways to steal.

Which is why the DMCB is turning once again to the President's Health Reform Proposal. Out of the 11 pages, there are three on attacking 'waste fraud and abuse,' and most of it is directed against the fraud part. There are items that pertain to following bad actors with a history of malfeasance (sort of like a Medicare 'no-fly list), background checks, real time as well as wider data sharing among various enforcement agencies, profiling increased penalties and greater enforcement lattitude.

We've heard this before (here and here, for example) and we're supposed to believe this time it's really really going to work. Trust me.....


And if the posture of the President's Proposal, when it comes to fraud, strikes you as borrowing concepts from the war on terrorism, then you may understand why some docs may fear being ensnared somewhere in that increasingly complicated grey zone that separates 'simple mistakes' and 'trying to take advantage of the Medicare system.'

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