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health care fraud

The Toninator

The Toninator

Muffin
Jul 6, 2001
5,436
17
High(ts) Htown
In 2002, the Federal government won or negotiated more than $1.8 billion in judgments, settlements, and administrative impositions in health care fraud cases and proceedings. As a result of these activities, as well as prior year judgments, settlements, and administrative impositions, the Federal government collected over $1.6 billion, of which approximately $1.4 billion was returned to the Medicare Trust Fund. An additional $59 million was recovered as the federal share of Medicaid restitution. This is the largest return to the government since the inception of the Program.
Federal prosecutors filed 361 criminal indictments in health care fraud
cases in 2002. A total of 480 defendants were convicted for health care
fraud-related crimes during the year. There were also 1,529 civil matters pending, and 221 civil cases filed in 2002. HHS excluded 3,448 individuals and entities from participating in the Medicare and Medicaid programs, or other federally sponsored health care programs, most as a result of convictions for crimes relating to Medicare or Medicaid, for patient abuse or neglect, or as a result of licensure revocations.

http://oig.hhs.gov/publications/docs/hcfac/HCFAC Annual Report FY 2002.htm
 
El Jefe

El Jefe

Dr. Phil Jefe
Nov 26, 2001
793
0
OC in SoCal
Originally posted by Serial Midget
I am of the opinion that 99% of administered healtcare is unnessasary and therefore fraudulent. If the diesese doesn't kill you the cure probably will.
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Well, opinions are like a$$holes...everyone's got one and they all stink.

You're dead wrong.

There are quacks out there, and there are those trying to pull a fast one on the feds, on commercial insurance payers, and in some cases on cash pay patients.... these cases however are not the majority, not by a long shot.

Here's the deal; Most doctors aren't living high on the hog like they were in the 70's. Back then, with indemnity coverage, the bill was the bill, and insurance paid it. Now, with managed care (HMO, POS, PPO, etc..) and the failure of the Fed to adequately adjust reimbursement rates to reflect the level of service and risk, doctors are getting squeezed. You have the Feds telling docs what they'll pay for certain procedures, and in some cases, the cost of doing business is greater than the reimbursement for the service provided. HMO capitation rates, fee for service contract rates, and case rates are based on a percentage of Medicare rates. It's fvcked up how the fed can basically determine how much doctors can get paid. Sure, your surgeon or physician can charge whatever he or she wants, but that doesn't mean they'll get paid nearly that amount. If a doc collects 35-50% of billed charges, he or she is doing pretty well.

Add on top of that the extreme cost of malpractice insurance, and it's a wonder why anyone chooses the medical profession these days. People will come in half dead from a gunshot wound, and then sue the surgeon who saved their lives because the patient suffered tracheal damage from the ventilator tube or had to have a limb amputated. Horrible horrible horrible how litigious people are these days, and it's driven the whole health care arena into a crisis state.

So what does that have to do with fraud? Well it's no wonder some of these docs are padding the books a bit. It cost so much to keep an office open, some see it as the only way. In my job, I do research, investigate and report on medical fraud, as I am a medical auditor and fraud examiner....it's part of my job to catch these things and deal with them internally (ie, issue refunds, have the doctor fired, etc...) before Medicare fraud examiners come in and slap us with a 22.5million dollar fine.....again..... but damn if I don't sympathize with the situation in which some of these doctors are placed.

So someone spouting off about how 99% of healthcare administered is fraudulent? Remember that next time you're sick as a dog or injured and need the lifesaving expertise of an MD...you ungrateful a............:eek: :rolleyes:
 
Silver

Silver

find me a tampon
Jul 20, 2002
10,840
1
Orange County, CA
I have a theory as to why Americans are seen as a lawsuit happy people, while Canadians are not. (This seems to be common wisdom, but like most common wisdom, I don't know if it is true or not.)

To take El Jefe's example, let's say you get accidentally shot in America. If there is any lasting damage from that, you could be paying for it for the rest of your life. How fair is that? Do we just leave it up to the luck of the draw? EDIT: What about getting hit by a car? That's an even better example.

You get shot in Canada, and the healthcare system takes care of most of it. You pay through your taxes, but on the flip side if you're sick, you don't have to break the piggy bank or sell your house to pay the bills.

I've brought this up before, and I'm going to do it again. Last time I went to the hospital at 1am, I got the bill because I had just switched insurance providers. 3 stiches over my eye after a hockey game: The bill was $1200. The doctor did about 5 minutes of work.

What the hell does having cancer cost?
 
The Toninator

The Toninator

Muffin
Jul 6, 2001
5,436
17
High(ts) Htown
Originally posted by Silver


I've brought this up before, and I'm going to do it again. Last time I went to the hospital at 1am, I got the bill because I had just switched insurance providers. 3 stiches over my eye after a hockey game: The bill was $1200. The doctor did about 5 minutes of work.
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What kind of insurance do you have? Er visits are covered under EVERY plan i know of doesnt matter how long you were on the plan. In fact in texas it's a state law.
 
Silver

Silver

find me a tampon
Jul 20, 2002
10,840
1
Orange County, CA
Originally posted by The Toninator
What kind of insurance do you have? Er visits are covered under EVERY plan i know of doesnt matter how long you were on the plan. In fact in texas it's a state law.
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It was covered, it was a couple days after the new month started, so instead of sending the bill to the insurance company, the hospital sent it to me.
 
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