Physician Reimbursement Fraud: Are You A Victim?
Have you ever been sedated with general anesthesia and wonder what is really going on? A patient came to the office for a routine tooth extraction and to have a tooth covered. After sedating the patient, the surgery began. The extraction went according to plan and we began to proceed to cover the damaged tooth. When the surgeon examined the broken tooth, he found that plugging would not be beneficial; but archive it. I felt that it was an act of generosity; saved the tooth and the patient did not have to file such a large claim with the insurance company. When the case was completed, the surgeon filled out the appropriate paperwork, filed it with management, and informed the patient that the tooth extraction and plugging went exceptionally well. As I was taking the patient out of the office, I looked at the bill, and under the procedure column, the CPT code to cover a tooth was marked as if that procedure had taken place. When I approached the surgeon about this, I suspected it was a mistake. How would you feel if a surgeon responded with “they (the patient) will never know, it comes out of the pocket of the insurance companies”?
The above account is an example of refund fraud. There are accounts of physicians committing fraud, yet the small number of dishonest surgeons is rarely detected. Refund fraud is a scheme used by employees / employers to claim higher pay when an action or motive was not carried out (Wynia, Cummins, VanGeest and Wilson 2000). This action is against the law and the sanctions for doctors involve: paying high fines, subject to imprisonment and possibly termination of practice. Deceptive CPT codes are the most effective form of reimbursement fraud in the medical field. CPT codes are a five-digit number that describe medical treatment procedures and aid in billing. Physicians can easily modify cost amounts by changing a number in the CPT code. By acting accordingly, the doctor has not only betrayed the patient, but has committed a crime and costs insurance companies thousands of dollars.
Refund fraud can be stopped in a number of ways. As a patient, after a procedure, demand itemized receipts for the charges that have been applied. This receipt will include all the procedures that were performed, the copayments charged if necessary, and the CPT codes. CPT codes will not make sense, but as a patient, you have the right to investigate what the code may interpret. Another way to protect yourself is to ask about scheduling a conference with the staff who were present during the procedure. In doing so, you, as the patient, reinforce your questions or concerns with an eyewitness. If you or someone you know suspects refund fraud, call 1-800-318-2596 (Palmer, 2013).
References
Palmer, P. (2013). How to report medical billing fraud. Retrieved from http://billadvocates.com/resources/report-medical-billing-fraud/
Wynia, MK, Cummins, DS, VanGeest, JB and Wilson, IB (2000). Medical manipulation of reimbursement rules for patients: between a rock and a hard place. Jama, 283 (14), 1858-1865.
