“Chuck, didn’t you just write about these guys?”
“No, that was a completely different clinic.”
“Why do they try to get away with it?”
“Because they can.”
On any given week, if I felt as though I could not possibly find a case of fraud, all I would need do is to look up the Department of Justice fraud cases under Medicare/Medicaid fraud and I would quickly find material. “Fortunately,” there is plenty of unethical behavior to go around. However, the amount of annual fraud (in the billions of dollars) is astounding.
Colonial Family Practice, LLC
Based in South Carolina with multiple clinics, Colonial Family Practice Clinics has agreed to settle with the government for $1.25 million for committing fraud.
This physician-owned primary and emergency care practice, filed numerous false claims with Medicare, Medicaid, and TRICARE (the insurance for uniformed services) for unnecessary services. The clinic was ordering an imaging test to detect kidney dysfunction.
This test is highly specialized and is permitted to be paid out for a small segment of patients. This clinic knew this, but went ahead and ordered the expensive test anyway. According to the DOJ:
“The former clinical manager alleged that between February 2012 and November 2019 physicians at the practice falsified symptoms in medical records to support unnecessary EKGs, laboratory orders, and radiology services.”
In addition, it is alleged that between August 2013 and November 2019:
“Colonial created a protocol to add a Cystatin-C laboratory test to its Basic Metabolic Panel, which led to systematic billing for medically unnecessary Cystatin-C tests.”
A Two-Way Street
It is no secret that there is a contentious relationship between medical practices and insurers of any type. Clinics constantly complain about insurers refusing their claims. The insurance industry, is viewed in broad strokes and they are portrayed as villainous and uncaring.
While I am certainly not an apologist for that industry (it would be unethical), there are numerous examples of abuse in the other direction. It has, unfortunately, become an unethical game.
Who loses? Ultimately, taxpayers and patients. When insurance is billed for unnecessary tests (or for tests never performed), they are more inclined, not less to scrutinize the claim. In the case of the tests claimed by the Colonial Family Practice Clinics, the office manager and the physicians knew quite well that the claim would be disallowed.
All too frequently, clinics will advise a patient “Oh, don’t worry, you’re probably covered.” This is not necessarily true. All too frequently, it falls back in the lap of the patient who can ill-afford to pay. In all too many of those cases, the clinic or practice merely shrugs its shoulders and walks away. The victim, the patient, is double-victimized by both provider and practice. I know this first-hand, as I am sure, many of you.
It comes down to ethics
Who advocates for the patient? Ultimately it must come down to all of us. When a medical practice “shakes its head” and speaks of the claims denied, we need to ask ourselves how many of those claims were necessary to begin with. While we naturally want nothing but the best for ourselves and our families, when recommending tests or procedures, we have the right to know if we are covered and what will happen if we are not?
While we assume the practice, physicians, office managers, PA’s and the like have our best interests at heart, how can we, as lay people, be certain?
Who in the Colonial Family Practice Clinics was responsible for the ethics of the practice? Who advised the physicians ordering the unnecessary tests that more than likely the claims would be denied? Further, who raised the possibility that playing with the insurance codes to gain more money for the practice would undoubtedly result in the government bringing legal action against the practice?
Unfortunately, I never run out of medical insurance fraud scandals to report because the medical community itself fails to self-police.
I understand why legitimate practices push the boundaries, but do they understand the ramifications for patients and those of us whose taxes support Medicare and Medicaid? Ethical training, industry-wide, is many decades overdue. In the game between provider and insurer, the patient is always the victim
Colonial Family Practice Clinics is now facing a $1.25 million settlement. It is difficult to feel sorry for them. Every choice has a consequence. Now, they have plenty.
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