[justjim]

Originally Posted by blueash

I would add that in my personal experience, n=1, the primary driver of excessive testing was not fear of lawyers but demanding patients who believed every cough needed a chest xray or later a CT. Every headache required a brain scan etc etc.

A simple reading of past medical threads here will find many postings from Villagers who helpfully suggest all the tests you should be getting for whatever medical symptom you post about.

You shouldn't worry about lawyers or malpractice if you don't commit malpractice and stay aware and conform to the standard of care. And yes, I am well aware that being innocent of malpractice is not the same as not being accused and dragged through the process.

But the original post here is correct. There is lots of fraud and firing the people who look for fraud is the exact opposite of cost cutting even if it saves the salary of the inspector that saving is completely cancelled by the lack of recovery of the fraudulent payments. And once the industries and individuals know there is no longer any oversight then the fraud, or creative accounting and billing will certainly get worse.

Same thing for IRS agents where they more than make up for their salary with increased collections of taxes owed, (a $1 increase in spending on the IRS's enforcement activities results in $5 to $9 of increased revenues. ), and the deterrent factor of not trying to get away with cheating adds even more.

I agree 100%. Many of the so called “layoffs” will actually cost much more than the salaries/benefits of the persons being fired/laid off.

As a former government employee who worked in a department that monitored/audited government contracts and grants more staff was always needed to monitor fraud and abuse not fewer employees. We had data that proved employees found three to four times his total salary in fraud/abuse more than the cost of his/her employment. However popular, firing/laying off IRS employees, social security and Medicare employees is counterproductive IMHO.

[CoachKandSportsguy]

Originally Posted by golfing eagles

Agree with you as well. As you know it is very hard to tell a patient that you are not going to order some ridiculous test that he looked up on the internet

Agree with BlueAsh.

My mom is in hospice, for losing weight, in memory care, 98, post broken hip surgery.

She fell, I was in FL, and the nurse from Hospice sent her to the hospital for something he thought didn't look right. I was like, describe it, I am not sure what you are seeing, not sure I agree from the descriptions I have been receiving about the severity of the fall, but OK.

Came back nothing wrong.
total encounter cost Medicare $15K.
Recommendations: higher dosage of ibuprofen for the bruises.

CYA or the fear of the effects of lawsuits are everywhere.

A great book to read is by a Boston Surgeon Atuwal Gwandi
Amazon.com

His description of the healthcare industry has come along way from the turn of the 20th center, 125 years ago. Some has been from the legal system forcing better practices.
However, the EMR of today are being created to prove behaviors are done, and that takes time, and can be very granular, and to push towards proactive medical care versus reactive medical care, which will always be there. Proactive medical care is very difficult and has a higher cost than pure reactive medical care

good luck to us!

[Stu from NYC]

Originally Posted by golfing eagles

Are you really trying to tell me how to take a history and physical???😂😂😂. Sorry, but it’s not that simple. The worst medical mistakes that I have seen have occurred when there was no in-person contact

We moved here a month after covid and the DR we found would only do telehealth visits for the next year. She had a family and wanted to protect herself. Perfectly understandable.

Nice to speak to her but she could not listen to our heart and lungs or look at our ears, throat etc.

A year later I pushed the issue wearing whatever she asked us to protect her and the visits were much more productive.

[bmcgowan13]

Originally Posted by ROCKETMAN

I think of all the fraud Medicare and Medicare would be in the billions.

And unfortunately it has been going on for some time. In 1997 Columbia/HCA paid the largest Medicare/Medicaid fraud FINE of 1.7 Billion.

This abuse has been going on for over 25 years and it appears we are no closer to having the safeguards in place to stop the grift or eliminate abusive and fraudulent billing practices.

Is UNH in the running to knock Columbia out of first place? How do we score? If adjusted for inflation Columbia's fine is equivalent to $3.3B in 2025...

[CoachKandSportsguy]

sample example of UHC which you as patients don’t see:

My wife is a Clinical Psychologist. I’ve been sending the @BillAckman & @EPotterMD posts to her as she has always told me how stressful it is to get payments from UNH. She said that around 50% of the claims that she bills to UNH get denied because of weird codes and when she has her office manager call to question the codes, the people on the other end have no idea how to explain them.

Then the UNH rep says they will resubmit the claim with additional paperwork and then that gets denied as well. Then when you call again they say “It’s beyond the date of service to be reimbursed”. She said it’s a total mind-bender and the hours of work it takes to try to get your money is not worth the time it takes away from your practice and other patients.

That’s why 70% of her colleagues in the Psychology/Psychiatry field don’t take insurance. With United, she mentally writes the loss off as unrecoverable theft. She says she treats United like a slot machine…pull it, and grateful if anything comes out. She does the Psychological evaluations for patients who are about to undergo certain surgeries and if she says she no longer will take United, those surgeons would no longer refer any evaluations to her.

She likens it to a teacher who only would want to teach the well behaved children. UNH is that out of control kid whose parents don’t give a damn.

[Sabella]

Originally Posted by golfing eagles

IMHO, the amount of fraud is in the tens of billions. Insurance companies adding diagnoses is fraud, same for hospitals and doctors.

"Unnecessary" tests are not fraud , and are driven by one thing and one thing only-----LAWYERS

It is estimated that the defensive practice of medicine costs us $600-700 BILLION/year. Want to cut costs?-----limit so called "pain and suffering" awards and penalize lawyers that bring frivolous lawsuits. There is real malpractice from unqualified or impaired providers, but that is a small fraction of what is going on---the majority of lawsuits are for "maloccurence"---a bad outcome through no fault of the provider.

.
Unnecessary tests and unnecessary medication‘s people are put on ensure big business repeat visits and keeps the patient constantly coming in. Medicine sad to say is no longer about a person‘s health. It’s about how much money you can make. PS aren’t you a retired doctor?

[Cuervo]

If there is fraud or not in the health industry is not the problem. When a service is provided by an outside company the main goal is profits not the well-being of their clients. I know there are numerous problems with universal healthcare and I'm not suggesting it is implemented here overnight. What I am suggesting is to take a deep study to see if the problems that come with universal healthcare can be overcome. If we can achieve that, maybe we can eliminate the middleman.

[elevatorman]

Originally Posted by bmcgowan13

And unfortunately it has been going on for some time. In 1997 Columbia/HCA paid the largest Medicare/Medicaid fraud FINE of 1.7 Billion.

This abuse has been going on for over 25 years and it appears we are no closer to having the safeguards in place to stop the grift or eliminate abusive and fraudulent billing practices.

Is UNH in the running to knock Columbia out of first place? How do we score? If adjusted for inflation Columbia's fine is equivalent to $3.3B in 2025...

Columbia/HCA pled guilty to 14 corporate felonies in this case. Previously the CEO of Columbia/HCA took the 5th 75 times in a deposition.

[golfing eagles]

Originally Posted by Sabella

.
Unnecessary tests and unnecessary medication‘s people are put on ensure big business repeat visits and keeps the patient constantly coming in. Medicine sad to say is no longer about a person‘s health. It’s about how much money you can make. PS aren’t you a retired doctor?

Yes, which is why I know that post is, well to put it politely, untrue.

Love to hear an example where a physician puts a patient on "unnecessary" medication.

I addressed testing in a previous post, as well as the obvious solution (other than kill all the lawyers)

[spinner1001]

Originally Posted by CoachKandSportsguy

If the government wanted to eliminate fraud, hiring more inspectors general and attorneys to prosecute, and increased the size of the court system for more throughput, would be the best answer, instead of cutting basic services. .

‘… hiring more inspectors generals who actually find and stop fraud, waste and abuse of taxpayer monies…’. Fixed it.

[defrey12]

Originally Posted by golfing eagles

On the other hand, telemedicine is a poor alternative at best. There is no substitute for talking to the patient in person and hands on examining them. NONE. You cannot practice medicine over the phone. PERIOD.

AMEN! People used to get the Dr’s prior to Covid…just sayin’. Or the Dr could come to them; I remember house-calls.

[NotGolfer]

I hated televisits during the "plague". I have rheumatoid arthritis and my RA dr. did those with me. How in the world can she determine what's going on with a computer screen?? I'm surprised she didn't also wear a mask. I'm being sarcastic of course but I try not to have a dr's visit with any of my practitioners unless necessary. I'm sure fraud has been around for a very long time. We'll see if "they" clean it up....or not!!

Years ago before we moved here, the dr. I was seeing would always order tests. I changed primaries because even then I knew they weren't warranted. This would have been in the late 80's, early 90's.

[CoachKandSportsguy]

Originally Posted by golfing eagles

Yes, which is why I know that post is, well to put it politely, untrue.

Love to hear an example where a physician puts a patient on "unnecessary" medication.

I addressed testing in a previous post, as well as the obvious solution (other than kill all the lawyers)

With all due respect, my cardiologist asked me to go higher on the statins due to the ever decreasing level recommendations of the use of statins.

hypothetical example:
So if my cholesterol level up was 200 before statins were recommended,
"they" now recommend statins if the level is above 100.
Now "they" are recommended above 70.

A close colleague had his doctor recommend statins because of his age. . mid 60s
not because of his test results.

so I am a beneficiary of statins, due to very high fossilization test results. .
not bashing doctors, but I think that is from where the "rumors" originate, particularly as received by different personality types.

Now going back to my post about proactive versus reactive medical practices, that conflict sometimes causes problems between the sensory personality types (this is what I see factually right now, no interrelations with future outcomes) and the intuitives (this what i see relates to how that might evolve in the future which relates to a future outcome)

The sensors prefer reactive medical and the intuitive prefer proactive medical advice.

all comes down to hoomans, and there are a bazillion different types of them . .
and doctors also fall into the different personality types of medicine. My wife's supervisor is a practicing hospitalist physician, and is very sensory oriented, well illustrated with his administration skills, for which he also has responsibility. if the administrative situation can't be found as having a previous diagnosis with recommendations, he has no answer. . zero answer. happens all the time.

good luck to us. .

[golfing eagles]

Originally Posted by CoachKandSportsguy

With all due respect, my cardiologist asked me to go higher on the statins due to the ever decreasing level recommendations of the use of statins.

hypothetical example:
So if my cholesterol level up was 200 before statins were recommended,
"they" now recommend statins if the level is above 100.
Now "they" are recommended above 70.

With all due respect, surely you are not suggesting that prescribing a statin was "unnecessary" given the LDL levels you cited. He was actually following the standard of care---if he DIDN'T prescribe them, that would potentially be malpractice.

Now, if we want to get deeper into the weeds, why has the "standard" become LDL < 100 and <70 with risk factors? Studies show that improves outcome, but who has funded those studies???? Food for thought.

[kendi]

Originally Posted by golfing eagles

On the other hand, telemedicine is a poor alternative at best. There is no substitute for talking to the patient in person and hands on examining them. NONE. You cannot practice medicine over the phone. PERIOD.

I don’t need hands on examining for my doctor to discuss and show me the results of my MRI.