Watch out for health care fraud

In my 30 years practicing emergency medicine it wasn’t unusual for a patient to come in seeking treatment by “borrowing” someone else’s insurance ID.

One patient I remember well came in complaining of chest pain. It turned out that the ID he was using belonged to another patient who I had treated several years before for a heart rhythm disturbance. Once we compared their EKGs, we realized these were two different people. The fraudulent patient didn’t have a heart problem. We discovered his deception before administering any drugs or treatments that would have been inappropriate, or even potentially dangerous to him.

This type of fraud is not only a problem for hospitals and insurers, but the fraudulent patient may receive treatment based on someone else’s medical history and the medical records of the patient whose ID is used can become distorted and inaccurate.

The annual price tag of health care fraud adds up to a staggering $226 billion, according to the National Health Care Anti-Fraud Association According to the White House, improper payments in the Medicare and Medicaid programs – including fraud as well as errors and mistakes – cost $54 billion last year. All of this is a huge drain on an already strained medical system.

How can we get a better handle on medical fraud to stop it? How can we reduce abuses and mistakes that illegitimately take money out of our system?

One of the best ways to protect ourselves is to prevent the fraud in the first place. Medicare and Medicaid, however, are required to pay claims within 30 days. This means that fraudulent claims are often not discovered until after they are paid.

Today, government, private insurers, medical professionals and individual patients are getting a whole lot smarter and using new, more sophisticated methods to spot the fraud early and stop payments. The challenge is to identify fraud while minimally inconveniencing legitimate patients and providers.

The Affordable Care Act includes tougher rules and criminal penalties, and expanded recovery efforts.

On July 22, President Obama signed the Improper Payments Elimination and Recovery Act, which extends to all federal agencies, including Medicare, efforts to reduce payment errors and fraudulent payments by requiring agencies to have corrective plans and targets for reducing errors and overpayments. This holds some hope for success. A Medicare pilot program that was carried out in a number of states over a three-year period recouped $992 million.

Insurance companies are also using advanced technologies and analytical software to sort through tens of thousands of providers and hundreds of millions of claims within minutes to search out fraud and abuse. Health benefits companies using these new systems have achieved a nearly 90 percent reduction in fraud, a sharp contrast to previous methods, which typically net 20 to 30 percent reductions. For example, Aetna’s special investigations unit was able to identify questionable claims at more than 200 facilities, and saved more than $20 million.

On an individual level, here are a few simple things you can do to protect yourself:

• Don’t give personal or medical information on the phone unless you initiated the contact and you know who you’re dealing with.
• Keep your paper and electronic records secure. When asked for sensitive information, such as your social security number, ask why it’s needed and how it will be kept safe.
• Shred health insurance forms, prescriptions and physician statements before you throw them away.
• Read the statements you get from your insurer and make sure the claims paid match the care you received.

Republicans afraid of debating health-care law?

I want to emphasize something that Nancy-Ann DeParle pointed out in our interview: The GOP isn’t banning discrimination based on pre-existing conditions. They just want you to think they are.

When I first read over the GOP’s “repeal-and-replace” language, I figured it wouldn’t work: You can’t ban preexisting conditions without also passing an individual mandate and subsidies for people who can’t afford care. Premiums will skyrocket as the sick rush into the system and the healthy rush out. This is partially what happened in Massachusetts, and it led a Republican governor named Mitt Romney to sign a bill that looked a lot like the Affordable Care Act. And you don’t have to believe me on this one. Just ask the National Review’s Ramesh Ponnuru.

But bad policy is one thing. Deceitful policy is another. And it looks like the GOP’s language was intentionally misleading. Under the heading “we will ensure access for people with pre-existing conditions,” the document mentions high-risk pools and reinsurance programs, and then says, “We will make it illegal for an insurance company to deny coverage to someone with prior coverage on the basis of a pre-existing condition, eliminate annual and lifetime spending caps, and prevent your insurer from dropping your coverage just because you got sick.”

On first read, that seems like they lifted the language direct from the Affordable Care Act. And Republicans have been using it all day to protect against charges that they’ll repeal the bill’s many popular parts. But notice: “to someone with prior coverage.” So it’s not the case that an insurer can’t turn me away for a long history of allergies. They just can’t turn me away if I already had their insurance. Which is both unimportant and already written into federal law.

Now, you might say the language is clear enough and it’s not their job to make sure everyone reads it closely. But when Norah O’Donnell interviewed Rep. William Thornberry, he either intentionally or unintentionally blurred the difference. Asked whether the GOP would repeal the Affordable Care Act’s protection for children with preexisting conditions, he waved the question away. “It says when we repeal Obamacare, part of the replacement is protection for people with pre-existing conditions,” he replied.

That’s just not true. But it shows the difficulty the GOP is going to have when they try to move the conversation from “should we pass Obama’s health-care bill?” to “should we repeal, replace, or stop funding Obama’s health-care law?” The bill is unpopular. But the component parts are popular. And even now, when Republicans have as much momentum as they’re likely to get, they’re afraid to say that they actually oppose what the bill does and they’re just going to get rid of all of it. But though these sorts of word games might work when people are skimming your campaign pamphlet, they don’t when you’re actually writing legislation.