Two Little Words

Fraud and abuse.

These two words represent to me everything that is wrong within our health care system. There are times when I get the impression that a Pandora’s Box has been opened by Medicare, and everyone is pulling out as many dollars as they can before it is emptied. When I see that the cost of providing medical services is outpacing all other services in our country, and that the United States is no longer No. 1 in providing good health care to our citizens, I become very concerned.

I read an article recently in a business journal that indicated in the United States $194 billion ($194,000,000,000) was spent for research and development. I smiled and said, “Yes, the U.S. is one great country.” But as I read further into the article, one number hit me in the face: It stated that $205 billion ($205,000,000,000) was spent on tort litigation. (I hope I have the correct number of zeros.)

Why so much for tort litigation? In the United States, about one-third of the students graduating from universities studied science and math. I think that is commendable, but the number should be higher. The very next paragraph said that in the United States we have more lawyers than almost the rest of the world. Ours is a litigious society.

I’m writing this because I had what I thought what would be minor surgery as an outpatient — but which became a bill to Medicare of nearly $25,000!

Prior to the surgery, a colonoscopy was ordered by my primary physician. From that point, it appears that many different practices were invited to share in the largess.

Invoices were submitted and paid to the physician, the endoscopic association, the surgical center, the colonoscopy center, pathology partners, a tissue exam group (in Texas?) and a national laser association. This was just for the colonoscopy, and these billings totaled close to $5,000.

The cost of the surgery, as an outpatient, included fees for the physician, chest x-rays, lab tests, a cardiologist, the hospital, stress tests, heart image, electrocardiogram reports, and so forth, and Medicare received invoices totaling nearly $20,000.

When I tallied the number of people and groups who submitted invoices for my short stay in the OR as an outpatient, I felt I was in the center of a feeding frenzy where everyone was trying to grab as many dollars as possible for themselves. In my case, it appears that as many disciplines as could be called upon were — and they all submitted invoices. The reimbursements they receive are not the amounts they shell out, or the country would be bankrupt.

When I spoke to the people at Medicare about the situation, they told me this was not at all unusual. A very nice lady in the Medicare office recommended that every Medicare patient should check all summaries carefully to determine that the procedures billed for were actually performed.

Note: Please take this message to every one of your Medicare patients.

In my opinion, milking the system in this fashion by billing for any possible procedure is, of course, to protect against a legal action. The problem is that I see no way to stop these outrageous billing techniques.

Hospitals all appear to be crying about these difficult times, but here in Florida where I live, many are adding more beds and building second hospitals. Salaries to their officials appear to be at an all-time high. Is this a way to demonstrate poverty? No, it shows me greed rules supreme. Who knows the answer? I don’t, do you?

What I have described may not be fraud, but it certainly is abuse.

Wrong Direction

It appears to me that our government is looking in the wrong direction to save its dollars. To cap payments for home oxygen or limit rental payments is not where they should be looking.

The average HME provider is an honest businessman who directs his energy toward providing the best service and comfort to his clientele. Home care companies and their patients should not be forced to carry this burden.

Sheldon “Shelly” Prial is based in Melbourne, Fla., with Prial Consulting and also serves as the director of government relations for Atlanta-based Graham-Field Health Products. In 1987, he founded the Homecare Providers Co-Op, now part of The VGM Group. He can be reached by e-mail at [email protected] or by phone at 321/255-3885.