The word on the street is that the estimated 10-year cost of expanding health insurance coverage is about $1 trillion.  President Obama, in repeated discussions, has indicated that the cost would be covered by re-covering monies that have been identified as sources of fraud, abuse and waste – in short, by turning up the heat on corporate compliance violations.  In theory, this should work.  In reality, not so much.

My experience as a Corporate Compliance Officer (for a public hospital) has been that monetary recoveries in health care fraud cases and proceedings were as a result of the violator filing false claims.  Medicare/Medicaid Fraud and Abuse Statutes were based on the False Claims Act that was initiated during the Civil War when vendors intentionally sold the federal government sick horses, rotten meat and other unusable goods.  The False Claim Act is “intent-based”, meaning that the government must show that a person (or entity) intended to defraud the government or acted in reckless disregard or deliberate ignorance of Medicare billing rules.   Current examples of this would be not collecting co-payments in your office or hospital, over-utilizing one procedure code, patterns of group coding or persons/groups being coded differently, inadequate documentation and using symbols that are not approved. 

Other high-risk exposure areas are high-volume practices, large numbers of Medicare/Medicaid disallowed claims, billing for services not furnished, sudden increase in billing for certain categories of items or services or billing for physician services provided by non-physician providers without adequate documentation by the physician provider.

My biggest fear is that the same practitioners, practices and  hospitals that are out there trying to provide good service to the additional 38 million “insured”, while trying to comply with corporate compliance policies and procedures and creating new P’s and P’s to remain in compliance will be the same entities that will be targeted.  Those areas that are targeted for oversight are high-volume areas, i.e., public hospitals and academic medical centers that have been targeted in the past and those practitioners that are already overwhelmed by the requirement to increase specificity of diagnosis, documentation of severity, complexity and level of care all the while trying to achieve legibility.  I think that there are enough practicing clinicians out there that have heard the horror stories and are smart enough to know not to “intend” to defraud the federal government.   How close to $1 trillion does the federal government think they will get from those who have learned their lesson or learned from the lessons of others?

I do recognize that the Department of Health and Human Services has done a yeoman’s job in the past in the detection and eliminating of health care fraud and abuse.  In 2000, the federal government won or negotiated more than $1.2 billion in judgments, settlements and administrative imposition in health care fraud cases and proceedings and, yes, $717 million was collected. (  Executive Summary). 

That was nine years ago; is that curve still trending upward?  And who will the Medicare Strike Force go after first?



About the Author

Ardena L. Flippin, MD/MBA is a professional speaker who focuses on the healthcare crisis facing corporations today.

Dr. Flippin, a Chicago native, is a retired board certified emergency medicine physician.

Topics #corporate compliance #health care reform #Medicare #Medicare fraud