Medical Billing – Fraud

Nobody wants to talk about it, but not talking about it isn’t going to make it go away. It is more common and more costly than most people want to admit to. It is one of the major contributing factors to our rising health care costs. It is very hard to prove and it is even harder to identify when it does happen because the people doing it have gotten very good at it. If you’re wondering what we’re talking about, it’s medical billing and fraud. We’re going to take just a brief look at the problem, as this is a topic that you could write books about.

Probably the most disheartening thing about medical billing fraud is that in order for it to be successful, in most cases anyway, more than one party has to be aware that it is going on. While we’re not pointing any fingers, this has become a joint effort. The best way to explain exactly what is going on and how this is a coordinated effort, is with an example, albeit a fictitious one.

A patient suffers an injury on January 1, 2006. The injury, because of the circumstances, is not covered. Maybe it was the patient’s own neglect. The reasons don’t matter. The injury isn’t covered under insurance so the patient just let’s it slide by. Six months later, the patient is involved in a car accident. While there are no injuries sustained in the accident, the original injury is aggravated and the patient can now claim that the injury they sustained in January of that year actually took place six months later while in the auto accident. All they need is a doctor’s say so.

This is where things get sticky. Yes, we can argue that the doctor is only human and can only go by what the patient tells him. But certainly, with today’s technology, the doctor should easily be able to tell if the injury the patient sustained happened yesterday or six months ago. The problem is that the tests that would need to be performed, in some cases, would be too costly to do. It’s just a lot easier to do a preliminary exam and certify that the injury must have occurred during the accident. The doctor then treats the patient for the injury, writes up his bill and sends it along to the insurance carrier. The claim is then paid for something that shouldn’t have been covered in the first place. Yes, maybe the injury was worsened by the accident, but if it hadn’t been sustained in the first place, the resulting injury may have not been as bad.

Splitting hairs? Maybe. But this is a borderline case. There are many cases of medical billing where the patient and doctor are both more than aware that this item should probably not be billed and hold their breath hoping that the insurance carrier won’t smell something funny and reject the claim. If you think this sort of thing doesn’t go on, spend a day at one of our courts and listen to all the cases of fraud going up before the judge. It’s enough to make you sick to your stomach for real.

The solution? For people to be honest. Is this going to happen? Well, we can always check with the courts six months from today.