At this point, it’s safe to say that you all have an inkling of how I think and the direction from which I approach topics related to health care. I have presented facts regarding issues that affect those with a financial stake in our health care system, which let us not forget includes doctors and patients (remember them?).
I have been critical of government “anti-fraud” efforts, mainly because a payment error isn’t always indicative of fraud. Sometimes, as we would expect with a confusing behemoth of a system such as ours, typical human error rules the day. I have been a certified medical coder for 14 years and I can tell you that every once in a while, two digits get transposed, not because I have a diabolical plan to buy a classic, mint-condition Ferrari Daytona by padding my wallet one office visit at a time, but because I’m human, imperfect and make mistakes. For further evidence of this, I direct your attention to the file marked “Marriage, First”.
It was with these thoughts in mind that I read a press release from CMS that hit my e-mail box yesterday. CMS proudly announced that they will now be teaming with assorted insurance carriers, insurance commissioners, the OIG, the FBI and an alphabet soup of insurance industry anti-fraud front groups to fight health care fraud with something of a united front. The partnership has the stated short- and long-term goals of information sharing, the ability to stop payments for the same patient on the same date from payers in different cities and using technology to predict and detect fraud schemes long before the damage is done.
There is one problem with this approach, as I see it. The two main players in this partnership, CMS and the insurance industry, are approaching the partnership with opposing sets of guiding principles.
The government, in the form of CMS and the Obama Administration, wants to eliminate waste, fraud and abuse in government healthcare. The Administration is desperately in search of good news news with regard to bringing improper payments under control, so much so that contracted entities such as the Recovery Audit Contractors (RACs) and the Zone Program Integrity Contractors (ZPICs) are now the beneficiaries of rules of combating overpayments deliberately tilted in the favor of the auditor. This is being done for no other purpose but to achieve the desired monetary results for CMS. After that, claiming success becomes a fait accompli.
On the other hand, the insurance industry wants to provide premium value to its stockholders. It is naive to think that the insurance industry has a goal that revolves around anything other than maximizing profits and retaining the maximum amount of money in premiums by consistently lowering the amount paid in benefits to health care providers and patients. When approaching the partnership from their particularly odious side of the fence, working with the government to lower “fraudulent” payments makes perfect sense.
To justify the partnership, CMS goes on to state that the partnership builds on efforts that, “have resulted in a record-breaking $10.7 billion in recoveries of health care fraud over the last three years”. Disputing that stated collection total, line-by-line, would provide fodder for my writings through the end of the calendar year. In other news, I turned approximately 25,000 years old on my last, record-breaking birthday, but bear in mind that I am human and prone to error.
Somewhere in CMS’ press release, facts go unstated. There are a lot of improper Medicare payments going out the door, the problem needs to be brought under control, and we need a fresh approach. Yet, if the goal of CMS is to build the trust of the provider community regarding payment integrity, teaming with the carrion-chewing vultures of the insurance industry may not be the best approach. Trust will come only when all participants in the process are devoid of a profit motive for conducting activities.
That sound you just heard was me not holding my breath awaiting that circumstance.