As has been noted, doctors who bill Medicare or Medicaid for tests and procedures done for personal purposes as opposed to what are medically necessary for patients, are committing fraud under federal and state Medicare/Medicaid programs. The law is so clear about this, that when this issue came up not once but twice at Congressional hearings this year, the doctors who first testified to performing unnecessary tests essentially wound up denying it when Members of Congress asked if they billed Medicare for them. Woops! (Make sure you check out the exchange between Troy M. Tippetts, MD and Rep. Jan Schakowsky (D - IL) when the transcript for this hearing becomes available. It was a beautiful thing.)
Anyway, low and behold, we were checking out the comments generated by this Huffington Post blog post by Center for Justice & Democracy Executive Director Joanne Doroshow, when we noticed something kinda stunning - physician commentators actually admitting not only that they routinely ordered unnecessary tests, but also that they knew precisely how to “outsmart” Medicare auditors so they wouldn’t get caught!
Here’s one from someone who calls him/herself “Boston Doc":
Today I requested additional consult ($300) and several additional tests ($247). This is of no benefit to the patient.… I can always prove in the court of law that the consult was necessary, even though I personally think it was not.
Second comment from “Boston Doc”:
No Medicare audit will ever find me fraudulent, because I know my field and my billing better than any Medicare audit. I AM THE EXPERT. I can justify any of my actions as 'reasonable and necessary', even if I know damn well that they are only necessary to me to make myself lawyer-proof.
“No death panels” defended “Boston Doc”:
A doctor could order ANY test to look for ANY condition that can cause chest pain-V/Q scan, CT scan, EKG, cardiac enzymes, O2 sat, etc etc-and could justify them all easily.
"Boston Doc" again:
Anybody who walks into ER with even the most trifle complaint could have a million dollar workup ordered. … In my specialty, I could triplicate cost of pathology diagnosis, and justify this with multiple publications and expert opinions.
“No death panels” continued:
How can a lawsuit-fearing physician be certain acid reflux might not be masking a pulmonary embolism or a pneumothorax, an esophagotracheal fistula, heart attack, aneurysm, cardiac tamponade, pericarditis etc etc.? Well, he can't. So he's gonna go right on testing. And if Medicare questions any of it, he's gonna say, “Hey, the patient was having chest pain.” And the auditors are going to have an early lunch that day.
(I don’t know about you, but I’ve got acid reflux and my doctor ordered Nexium.)
There goes that “God Complex” thing again. I know they may think they are above the law, but turns out, they’re not! So to all the Medicare auditors out there, you are welcome. Lets get some of that money back!