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My Turn
Our Small Acts of Fraud
Adam Dorin
Publish Date: October 10, 2007

By strictly adhering to and enforcing the healthcare fraud laws that are already on the books, we could pay for the 43 million uninsured Americans to have basic HMO insurance. Here's just one example from my specialty of anesthesiology.

What's 15 minutes?
Unless documentation states a rare, extenuating circumstance such as a code or placement of a central line, Medicare guidelines clearly state that anesthesiologists can't bill pre-op time they spend with a patient starting an IV line or taking a history and physical before the patient enters the OR. This time is considered to be part of the base units of a case. Anesthesia bills consist of time units and base units, with occasional modifier units contingent on such factors as patient age and positioning.

Despite this, it had been routine for anesthesiologists and nurse anesthetists to bill for 10, 15, 20 minutes at the beginning of a case before they enter the OR.

As one 15-minute time interval in anesthesia is reimbursed by Medicare at an average rate of about $18 (varies slightly by locality), you can see that even an error of one or two time units per case multiplied by millions of anesthetics can add up to hundreds of millions of dollars per year for just one area of billing, in one specialty of medicine alone.

Basic mathematics and ethics
Since the rewriting of the False Claims Act in 1986, more than $12 billion has been recovered in healthcare fraud alone, estimated to be only a fraction of the actual fraud being committed on an ongoing basis.

Thanks to the excellent work of the American Society of Anesthesiologists in distributing Medicare compliance rules and regulations and encouraging their members to be vigilant and take responsibility for appropriate internal compliance and billing practices, anesthesiologists are generally reliable and fair partners in enforcing existing rules on medical billing.

Yes, the laws governing the financial transactions surrounding Medicare, Medicaid and other insurance patients are too complex. There are bound to be errors. This is true. Nevertheless, there are egregious crimes being blatantly committed, and there needs to be some system in place to root them out.

If we healthcare providers spent less time trying to circumvent existing regulations (attending conferences on how to work loopholes in the wording of billing rules, for example) and more time playing by the rules, maybe there would be enough savings to give a few more people access to health care in the United States.

Critics will decry a traitor in their midst. They may be right. If the American way is cheating on taxes, and the moral equivalent of driving through life with a radar detector - breaking as many rules as possible in the pursuit of personal gain until one gets caught - then I am a traitor. A proud one.

DID YOU SEE THIS?