The new health care law passed in 2010 gives Medicare and Medicaid more teeth to fight back against corporate health care fraud, such as subjecting healthy patients to unnecessary and dangerous procedures and overbilling the government programs, a USA Today report claims.
The law will make it easier for Medicare and Medicaid to track and reject unneeded medical procedures, such as implanting healthy patients with unneeded heart stents – a practice that HCA, the nation’s largest for-profit hospital chain, routinely practiced in some of its Florida hospitals with an elderly patient base, according to a New York Times investigation.
According to USA Today, records and interviews with health care experts show “the law and the 2009 stimulus act will change payment incentives and allow physicians to use electronic records to limit unnecessary medical testing. Private insurers will also be able to work with government agencies to combine billing data to spot trends in overused procedures.”
“The health care law is helping us implement new incentives for doctors, hospitals and health care providers to provide better quality care, and not just a greater quantity of services,” Medicare spokesman Brian Cook told USA Today.
In 2010 alone, the Department of Health and Human Services reported $48 billion in improper Medicare payments involving unnecessary procedures performed for profit, unneeded and redundant tests, medical mistakes, and other errors.
Jordan Battani, managing director for CSC’s Global Institute for Emerging Healthcare Practices, told USA Today that these problems stem from “an antiquated fee-for-service system that encourages providers to perform as many procedures as possible.”
“The Affordable Care Act is changing the way we pay for health care,” Ms. Battani told USA Today. “We have incentives to do a lot of stuff. The more you do, the more you get paid.”
The government is currently looking at alternatives to compensating health care providers on a patient-by-patient basis, a system that makes identifying fraud and errors cumbersome and often impossible. One option is to identify how many Medicare patients fall under a hospital’s service area, for instance, and then compensate the hospital for that entire group. Under such a system, health care providers would lose the incentive to perform unnecessary procedures on patients and instead adopt a more conservative approach to spending taxpayer dollars.
According to USA Today, under the new plan “the provider ends up with both healthy patients who don’t need a lot of care, as well as patients with diabetes or heart disease who need more care. The provider receives a budget, and makes money based on how much can be saved. To make sure providers continue to give good care — rather than cutting tests or procedures to save money – the government has also created quality measures.”
In 1863, Congress enacted the False Claims Act (FCA) to hold individuals and companies responsible when they defraud governmental programs. The FCA includes what is called “qui tam,” shorthand for a Latin term, a provision that allows a person not affiliated with the government to file claims on behalf of the government. This has come to be known as “whistleblowing,” because the person is drawing attention to fraud, or “blowing the whistle” on foul play.
The “qui tam” provision of the FCA allows citizens to sue on behalf of the government and be paid a percentage of the recovery. An attorney who handles this type litigation can help you determine if there is a case of FCA violation. More information is available on the Beasley Allen website.