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Charlie Mitchell: Sunshine best remedy for Medicare, Medicaid fraud

 

Charlie Mitchell

 

OXFORD -- When state and federal programs to health-care providers began, so did a behind-the-scenes struggle. It centered on keeping the payments secret. 

 

The driving force in this effort for blocking release of the information been the American Medical Association. Yet now, in a deal with the Obama Administration, the AMA has agreed to call off its lobbyists and let the sun shine in. 

 

Hooray. 

 

Nothing -- not one thing -- is a better remedy to both uphold the reputation of reputable providers and to expose billions upon billions of flagrant fraud and abuse that infect the programs. 

 

How flagrant? 

 

Consider that one physical therapist -- not a doctor -- billed Medicare for $4 million in 2012. According to The New York Times, that means each of the 1,950 people listed by the firm as clients would have received 94 treatments that year. The clinic would have provided 183,000 treatments total, or 500 per day, 21 per hour. 

 

Consider that, as it happened, each and every one of the 1,950 clients also needed the full range of preliminary tests and evaluations -- every one that Medicare will pay for -- before treatment began. 

 

Consider that eight of the top 10 Medicare billers for physical therapy are neighbors of the ringleader, all in Brooklyn, N.Y. 

 

How do such travesties arise? 

 

Through secrecy, yes -- but there's another almost equally troubling factor. 

 

It is this: Hospitals, doctors and clinics want their money. Thanks in large part to the medical lobby, CMS, the government contractor that serves as paymaster, has been required by federal law to send checks no more than 30 days after receiving invoices with approved provider numbers. 

 

It doesn't matter if the invoice shows that Donald Duck was picked up at a nursing home in Seattle and taken to an appointment in Maine. If the coding is right, a check goes out. 

 

Then, ostensibly, one of a handful of investigators follows up on "suspicious claims." It is those investigations that lead to the occasional news stories about mass fraud. There are rarely arrests because more often than not a "provider" will have used a rented postal address and will be long gone before anyone shows up to investigate. 

 

Easy pickings doesn't being to describe such a situation. 

 

As for its rationale against disclosure, the AMA had several pages of reasons, which could be summed up as, "We think people are too dumb." 

 

For instance, printing the amounts paid would not reflect the quality of care, local factors such as regional pricing differentials and (my favorite) that people would not understand that providers' expenses would have to be paid out of the checks they received from Uncle Sam. 

 

Of course, we're smart enough to know that when a contractor is paid $24 million to build a new high school, the contractor doesn't keep all $24 million. We're smart enough to know that when we read that a new bridge, paid for with public funds, will cost $50 million we know the largest chunks go to labor and materials with some reserved for taxes and profit. 

 

But the AMA insisted that if people read that a dentist in Tutwiler billed $25,000 per year, people would think the dentist kept every penny. 

 

Even after the AMA agreed to back off, the organization was miffed that CMS released the first wave of information before providers had a chance to review and prepare for media inquiries. 

 

"The American Medical Association is committed to transparency and the availability of information for patients to make informed decisions about their medical care," said AMA President Ardis Dee Hoven, M.D., in a statement. "We believe that the broad data dump today by CMS has significant short-comings regarding the accuracy and value of the medical services rendered by physicians. Releasing the data without context will likely lead to inaccuracies, misinterpretations, false conclusions and other unintended consequences." 

 

Harrumph. Harrumph. 

 

As these things go, not every amount paid to every provider is being place on a website. Congress and the president may turn tail. They have before. 

 

Admittedly, the payments aren't generous. Providers get much less for Medicaid and Medicare clients than they do for private pay or privately insured patients. 

 

Still, a really effective weapon against fraud would be to require all providers to post their Medicaid and Medicare billing and, perhaps, a comparison chart. 

 

For example, the average physical therapist in Brooklyn billed $49,000. Think people would have figured out something was awry when they saw one next door billed $4 million?

 

 

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