The $8.5 Million Fraud Case

Larry already beat me to sharing this information.  Here is a different perspective from Jef Henninger, an attorney in New Jersey.  For me, multiple issues come to mind.

Healthcare Reform:  The language Jef used in sharing his perspective suggests Dr. Khashayar Salartash obviously had at least one physical therapist on staff and services were billed "incident to."  The portion of fraud to Medicare was pretty close to $5 million.  As healthcare reform is analyzed, how much of a cost savings could occur with the elimination of referral for profit situations (physical therapy services included)?  Not only is there a higher frequency of use to figure in the calculation, but what about fraud?  In this particular fraud case, I would tend to believe the 1.5 to 3 year treatments were probably the red flags that created an audit.  As the auditors dug deeper, more issues were found.  Services provided by a physical therapist were not supervised... oops.  Services provided by a physical therapist were billed as surgery... oops.  Services provided in the physician office were billed as if they were provided in an outpatient facility... oops.  That's a lot of "oops."

Professional Accountability:  Think about your last staff meeting.  How transparent is your company?  Forget about referral for profit for the moment.  I bet after every patient you complete a charge sheet, or your electronic medical record determines the procedural codes and units for the services provided, right?  Do you know where that information goes?  Do you know on a monthly basis what procedural codes you use and the frequency in which you use them?  I'm willing to bet your supervisor can tell you your productivity - the number of units billed per hour and the number of units billed per day.  Maybe we need to speak up and request monthly reports on our claims data - procedural codes and their frequencies.  Is it reasonable to keep our heads in the sand and only focus on the clinical portion of day to day operations?  Is it reasonable to assume what we report for claims is what is generated on a claim?  I guess what I'm basically asking:  if the right hand knew what the left hand was doing could there be a reduction in fraud in our particular field if information was shared?

Quality:  1.5 to 3 years of treatments... need I say more?

Patient Centeredness:   In this particular situation, the patient got the short end of the stick.  I'm willing to bet the majority of the patients had secondary lymphedema.  That means the majority of the patients either had surgery, had an infection or were fighting cancer.  (Here's some quick info for those of you not completely familiar with lymphedema.)  Fraud cases always focus on the money... and it isn't just a money situation.  The lives of all the individuals in this particular case were obviously affected.  The patient had no idea the surgeon was focused on profits, had no idea the pleasant physical therapist probably wasn't competent, and had no idea 1.5 to 3 years of treatment was unacceptable.  What does it literally mean?  The patient probably still has a sausage of a limb due to a failure in the system.

~Selena