[Aces4]

Originally Posted by golfing eagles

And some other estimates are as high as $105 billion. But I think we need to clarify what is being loosely thrown around as "fraud". I believe the definition of fraud is intentional misrepresentation (legal dictionaries agree). If I believe my SUV is in good working order and sell it to you, and it turns out it's a lemon, it is NOT fraud. If I knew and concealed it, THEN it is fraud. If I believe I correctly documented a patient visit as a 99214, but CMS disagrees, IT IS NOT FRAUD. It's only if I knew it didn't meet the criteria and billed that code anyway that I committed fraud.

Now that the definition is clear (sorry to the hundreds of posters that are accusing TVH of "fraud"), there is the question of what is included in that $60-105B estimate:
First there is outright fraud, medical practices that were set up for no other purpose than to bill Medicare millions for unnecessary work or services that were never performed. These are usually fly by night clinics owned by somebody with a bogus medical degree from the Caribbean that pays winos and homeless people cash and a bottle of thunderbird to come to their clinic and have "tests", or just say they did. They are usually gone by the time CMS catches on, and doing the same thing under a different name. California, Arizona and Florida are notorious for these.

Then there is gray zone "fraud". Coding aggressively but not necessarily having the documentation to support the submitted codes. If this is intentional it might be fraud, but like I said, it's a gray zone. And believe me, I can turn even a 3-minute visit for a sore throat into a 99215 (highest level of office visit) if I was so inclined. How is that possible? Because it is no longer important what you doctor does, only what he writes. Thank the bean counters at CMS and insurance co. as well as lawyers for that one. The result, for some less scrupulous physicians, is that they would rather spend 2 minutes with the patient and 10 minutes documenting that visit--far more lucrative.

And then there is "overbilling" or "miscoding" or "computer error" or "misinterpretation of ICDM-10 and CPT" or whatever you want to call it. This is devoid of intent, and also subject to interpretation of the vague guidelines.

So, what are the safeguards?
For the fraudulent practices, it involves CMS and DOJ identifying them, usually because their billing is way more than similar sized legitimate practices. But again, they have a tendency to disappear off the grid until they re-emerge elsewhere.

For the aggressive coders, CMS knows the bell curve of CPT E&M charges and can identify anomalies. They would then ask the practice to submit 25 or 50 progress notes for review to see if the documentation supports the coding, and pay the practice a "visit" if they are out of compliance. For one group of cardiovascular surgeons in Syracuse, that visit was by the FBI with M-16s in full body armor while their waiting room was packed with their patients.

For the other 95% of practices that wants to play by the rules, it starts with internal chart review. In our group of 6, we just reviewed each other's notes and coding. In large practices like TVH, they have outside consultants that perform that task. And this is where the TVH case get murky. (Hypothetically), those outside consultants told TVH that they were in compliance with the rules. Also, hypothetically, later reviewers disagreed. And like all practices they also had to send CMS charts to review periodically, so I don't understand how any "overbilling" didn't come to light years ago. Now, and to appease certain others on TOTV, I will term the following "conjecture". The chart review at CMS was conducted by low level staff who either didn't catch it or more likely also thought it was legitimate. But with all the hoopla with Humana and UHC as well as a very large number being thrown around, it caught the attention of a higher level bureaucrat, and probably one with even higher ambitions.

From my experience, if CMS finds what is overbilling in their opinion, you can appeal or just give them some money back. But I don't think anyone wants to try to give $361M back. Of course, we don't know exactly what period of time might be involved, if that number is accurate, and whether or not it includes interest and penalties, which would be negotiable.

I just want to reiterate that no one on TOTV, including myself, knows what happened. And it will take time for this to all settle out.

In the meantime, I agree we are in a mess. TVH has 50,000 patients. Already at least 2 doctors are trying to leave. We don't have enough physicians for our population as it is, and any mass exodus will spell trouble. And not only for patients of TVH---those patients will start flooding other practices, and those that can't find a new PCP will end up in urgent care and ER's. In turn, anyone with a real emergency may be walking into a logjam. So let's hope they get acquired or bailed out before it's too late and table the recriminations until we know the population will be cared for.

Possibly a billion dollars in false payments..yeah, couldn't be any fraud anywhere. I'd like to see a computerized tracking device for the care of Medicare patients. Hand the tracker to the patient for when they enter the office, time the MA or nurse spends in the room and actual time Dr. is in the room.

I had a pretty good Dr. but this Dr.'s. caseload is in overload. The last two yearly visits had me waiting in the room for 40 minutes after the scheduled appt., I get that. But then this Dr. spent 7-8 minutes with me for the yearly followup. I get that, the Dr. is behind. But when I see it come through Medicare charged as a long visit, it torques my jaw. The Dr. should be paying me for wasting my time and then overbilling.