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Medicare Non-Fraud


“Because insured patients are paying so little out of pocket for care, we don’t closely monitor the cost.”

Hmph! Now I have personal knowledge of one of the countless reasons why Medicare has become so costly.

I have Medicare benefits now and also supplemental insurance, and the latter always reports back on my charges. I recently got an “Explanation of Benefits” pertaining to an ankle I fractured on New Year’s Day. I was amazed to see a charge for $320.59 for “Surgery,” so I decided to be a good citizen and report what looked like an error.

I was unhappy about this, not wanting to think ill of my doctor, whom I had greatly liked. He was very amiable and encouraging and provided me with a boot at the first appointment. During the next two appointments, he simply tested the growing strength in my ankle, expressing amazement at how quickly I was healing. On the last visit, he jovially dismissed me with a prescription for physical therapy.

When I called the Fraud Hotline, the woman at the other end seemed tired and discouraged–what a job–and I hated to dump my concern on her. I gave her the details, and she excused herself briefly to investigate. When she came back on the line, her voice was rueful. “I have no idea why they’ve done this,” she said, “but a fracture is coded as surgery, and this is correct.” I told her that I was relieved but could see how Medicare will go broke. She chuckled in agreement, updated my information, and wished me a nice day.

After I hung up the phone, I puzzled over this for a while. If I had been paying the doctor bill out of pocket, I would have been screeching. Now I’m just curious to see if that surgery charge will be repeated when I see the bill for my next two office visits.

Insurance is good in that the pool covers the cost of very expensive procedures, but it has a terrible downside. Because insured patients are paying so little out of pocket for care, we don’t closely monitor the cost. The result is that physicians’ fees and charges for questionable diagnostic services have exploded. A secondary problem is that because we are out of touch with the cost of healthcare, we are also out of touch with the wisdom of trying to live healthier lives.

In You Can’t Afford to Get Sick published in 2009, Dr. Andrew Weil writes that the Center for Disease Control estimates that each year 1.7 million Americans die and 25 million more are disabled by chronic diseases that are caused or exacerbated by lifestyle factors. However, there is little incentive to alter lifestyle when insurers beat the marketing drum with the message, “We’ll take care of you.”

When you’re unwell, you’re also probably not very inclined to police charges and coverage. And sadly enough, the Medicare population will become steadily less capable of jousting over details as both mental and physical strength decline. With the huge population of Baby Boomers heading toward sunset, we are looking at burgeoning costs for that reason alone.

And there must be countless bizarre Medicare administrative policies–like the surgery code for a fracture–that open the door to the pillaging of resources, whether calculated or not. For example, a Medicare friend was recently reviewing the expenses for his hospital stay and saw a charge for oxygen on his room bill. He called the hospital to protest, saying he had never used any oxygen. “But it was available,” was the retort.

So one looks at the medical community serving the elderly and asks, Why use a code that doesn’t apply? “That’s the procedure,” they’ll say. Why accept compensation for a service you didn’t provide? “Because it’s available.” Maybe we should shake up the whole healthcare industry a little by doing whatever it takes to stay as fit and healthy as possible for as long as possible. What’s the incentive? It could be fun.

3 Responses to “Medicare Non-Fraud”

  1. celeryellen

    Many thanks, and I had expert help with the design. Have been blogging since February.

  2. Merrill Heath

    I’ve just started reading your blog, Ellen, and this is an interesting article. If you want to see how badly out of whack our healthcare expenses are, just look at your next insurance statement. Look at the submitted charges compared to the eligible charges, which the physician accepts as payment in full from the insurance company. Why not just charge the “eligible” amount and be done with it? Well, the answer is obvious. But it’s totally screwed up.

    • celeryellenheath

      Dear Merrill,

      I’ve been having computer problems and just found this, so thanks very much for your input. Totally agree with you on how screwed up the system is. Now I’m really going to be watching.