Towards honest Medicare billing practices

In an industry characterized by the highest level of professional integrity and honesty, it is strange yet true that health insurance related fraud and abuse have reached alarming heights. While the incidence of fraud and abuse are equally spread across the health insurance continuum, it’s more intense in Medicare. In fact, a reliable survey (by the American Society of Business & Behavioral Sciences) puts the cost of such Medicare fraud and abuse at a staggering $700 billion annually, which is close to one third of the total healthcare spend. What is even more frightening is that that 80 percent of healthcare fraud is committed by hospitals, clinics and medical providers themselves! While the Federal Government has set up a recovery mechanism, the percentage of recovery against the eroded Medicare expenditure has been rather dismal – roughly about 5% of the expenditure lost to Medicare fraud and abuse is recovered annually.

While the unscrupulous hands have stood to gain (rather dishonesty), it is the Medicare that has to bear the brunt – the Sustainable Growth Rate (SGR) has grown so monstrous that the Federal Government is on the brink of introducing cuts to Medicare reimbursements. To compound the matter even further, the mandated transition from ICD-9 to ICD 10 could make Medicare even more prone to fraud and abuse. As diagnostic codes will increase from 14,000 to 69,000 and procedure codes will increase from 3,800 to 72,000, there is an undercurrent that more complex the coding system, the greater the opportunity for fraud & abuse.

Although the Federal Government has a stringent policy in place for penalizing unscrupulous intentions, yet the duality of the menace – wherein beneficiaries and providers contribute equally to fraud and abuse – and the unholy nexus between them – wherein they collude for unholy gains – have rather been tougher challenges.