Much of what we accept as legal in medical billing would be regarded as fraud in any other sector.

I have been circling around this conclusion for the past five years, as I’ve listened to patients’ stories while covering health care as a journalist and author. Now, after a summer of firsthand experience — my husband was in a bike crash in July — it’s time to call out this fact head-on. Many of the Democratic candidates are talking about practical fixes for our high-priced health care system, and some legislated or regulated solutions to the maddening world of medical billing would be welcome.

My husband, Andrej, flew over his bicycle’s handlebars when he hit a pothole at high speed on a Sunday ride in Washington. He was unconscious and lying on the pavement when I caught up with him minutes later. The result: six broken ribs, a collapsed lung, a broken finger, a broken collarbone and a broken shoulder blade.

The treatment he got via paramedics and in the emergency room and intensive care unit were great. The troubles began, as I knew they would, when the bills started arriving.

I will not even complain here about some of the crazy-high charges: $182 for a basic blood test, $9,289 for two days in a room in intensive care, $20 for a pill that costs pennies at a pharmacy. We have great insurance, which negotiates these rates down. And at least Andrej got and benefited from those services.

What I’m talking about here were the bills for things that simply didn’t happen, or only kind-of, sort-of happened, or were mislabeled as things they were not or were so nebulously defined that I couldn’t figure out what we might be paying for.

Continue Reading When your medical bill amounts to fraud

Whistleblowing is good for our health. Not necessarily the whistleblower’s health. But, while we’ve been watching the battle over whistleblower protection in Washington, insiders have been busy flagging health fraud.

As a result, there are patients out there who may have been spared unnecessary spine surgery or viscosupplementation injections. As a bonus, the rest of us won’t have to pay for them through Medicare.

In its October announcement of a $7.1 million settlement with the now defunct Osteo Relief Institutes, the Department of Justice (DOJ) describes viscosupplementation as a treatment for osteoarthritis “in which a doctor injects a gel-like fluid into a patient’s knee joint to act as a lubricant and to supplement the natural properties of joint fluid.”

But the clinic didn’t quite get it right, according to the DOJ.

Continue Reading Healthcare whistleblowers have your back, and your knees

The False Claims Act (FCA) has long served as a powerful weapon against fraud and waste in government programs, from rancid Civil War rations to Medicare scams. The Department of Justice (DOJ) recovered $2.88 billion under the law last year, with whistleblowers involved in the majority of cases.

March 2 marks the anniversary of the law, which was signed in 1863 by President Abraham Lincoln. After the Civil War, the FCA continued to identify military contractors guilty of mismanagement and fraud. With rising health costs, much of it covered by Medicare, most cases now involve medical providers and suppliers. The DOJ’s December report noted that $2.5 of the $2.8 billion in recovery involved the health care industry. The first line of a story in the trade publication Modern Healthcare reports “Healthcare industry groups have always hated False Claims Act whistleblower lawsuits.”

Continue Reading For more than 150 years, the False Claims Act has been key to ferreting out fraud in US military and health care spending.