Natural Beauty Breakthrough

Posted By Sofia Schonell on January 17, 2011

“How would you like to earn more money without working harder?” Such propositions, offered by overly aggressive sales representatives or unscrupulous business partners, have led many physicians to run afoul of the law. The manufacturer of a prostate-cancer drug, for example, encouraged urologists to bill Medicare for the free samples they provided to patients and offered the urologists extra free samples in exchange for purchasing more of the drug — though federal law prohibits physicians both from billing for free samples and from accepting remuneration in exchange for prescribing a company’s product. Several urologists ended up paying tens of thousands of dollars in penalties for participating in the manufacturer’s plan.

Another physician paid a $107,000 penalty for charging Medicare beneficiaries an annual “concierge” fee to cover an annual physical exam, same-day or next-day appointments, dedicated support personnel, around-the-clock physician availability, prescription facilitation, expedited and coordinated referrals, and other amenities. Physicians who participate in Medicare may charge Medicare beneficiaries only defined copayments or deductibles for Medicare-covered services. Since some of the concierge services were already covered by Medicare, the physician was charged with double billing, in violation of the Medicare assignment agreement.

Most physicians are honest, earning respect and trust from both payers and patients. But these cases are not isolated. Numerous other U.S. physicians have served prison terms, paid hefty fines, or faced other civil, criminal, and administrative penalties for accepting kickbacks, upcoding bills, or making improper self-referrals. More than 5000 physicians are currently excluded from participation in the federal health care programs because of these types of violations and cannot treat any of the approximately 100 million Medicare and Medicaid beneficiaries.

Health care fraud costs taxpayers an estimated $60 billion a year. To help fund the expanded access to care promised under health care reform, lawmakers propose to redouble the government’s efforts to reduce fraud, waste, and abuse. My office, the Office of Inspector General (OIG) of the Department of Health and Human Services, is tasked with protecting the integrity of the Medicare and Medicaid programs and the health and welfare of program beneficiaries. Educating physicians about laws designed to prevent fraud, waste, and abuse would help them to become partners in this mission and help keep the money currently lost to fraud, waste, and abuse in the system to buy care that patients need.

Medicare fraud strike forces have uncovered numerous durable medical equipment (DME) companies that were founded to scam Medicare. Investigations revealed shuttered storefronts in vacant strip malls that bill Medicare millions of dollars per month. These sham operations never opened for business and never intended to provide a single piece of medical equipment to a patient in need.

Unlike corrupt businesspeople setting up DME shops, physicians don’t join the medical profession for the sole purpose of bilking the federal government. No college junior studies organic chemistry and takes the Medical College Admission Test planning to devote 4 years to medical school and 3-plus years to residency and fellowship just to cheat Medicare and Medicaid. Various factors, such as greed or carelessness, may contribute to improper behavior by physicians during their careers, but ignorance of the law need not be one of those factors. Better education can provide honest physicians with a road map to keep them from losing their way.

Unfortunately, medical schools and residency programs do not uniformly teach trainees about fraud and abuse. In April 2010, the OIG surveyed all medical school deans and designated officials for institutions that sponsor residency and fellowship programs to determine whether their institutions provide education about fraud, waste, and abuse; to identify knowledge gaps; and to determine how the OIG could best promote education about compliance with the relevant laws. About two thirds of the designated institutional officials (among whom the response rate was 59%) and 44% of deans (response rate, 82%) reported that their institutions provide at least some training on fraud and abuse for students, residents, or fellows.¹

Although it is promising that many institutions already offer some instruction, the potential knowledge gaps may be greater than the survey results suggest. The fact that some instruction is offered does not necessarily mean that all students, residents, and fellows participate in comprehensive training. Survey responses may also overstate the availability of training, since some deans and officials may have purposely failed to return the survey or otherwise avoided admitting to the OIG that their programs lack compliance education.

Several institutional officials reported that although they were not currently teaching about fraud and abuse, the OIG’s inquiry alerted them to the importance of such topics and they planned to include relevant instruction in future curricula. Almost all survey participants recognized that compliance education has potential value. Only one representative of a medical school association opined that medical schools should not spend time teaching about fraud and abuse because they must be fully engaged in “teaching students how to be doctors.” Most physician educators conceded that in the current health care system, maintaining proper financial dealings with federal health care programs is part of being a physician. Perhaps honest and accurate billing and recordkeeping are not integral to a physician’s professional identity in the same way as grading a heart murmur, removing an appendix, or diagnosing an ear infection, but as long as the business of reimbursement remains part of the practice of medicine, these skills will remain essential for physicians.

The first step toward ensuring that all future physicians learn about fraud, waste, and abuse is to get medical educators to recognize the importance of teaching about the integrity of the Medicare and Medicaid programs. The next step is to help them develop the tools to effectively and comprehensively teach this topic. In the OIG’s survey, almost all respondents (92% of medical school deans and 91% of designated institutional officials) indicated that they want the OIG to help develop teaching materials.

The OIG has therefore created an educational resource called “A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse,” available online at www.oig.hhs.gov/fraud/PhysicianEducation.² This document summarizes the main federal fraud and abuse laws (including the False Claims Act, the Anti-Kickback Statute, and the Stark Law) and provides tips on how physicians should comply with these laws in their relationships with payers, vendors, and fellow providers.

In addition, the booklet engages physicians as partners in protecting the federal health care programs and their beneficiaries from fraud, waste, and abuse. For example, it directs physicians to resources to help protect their patients from medical identity theft and helps physicians to identify and report improper marketing and advertising practices by pharmaceutical and device companies. The OIG has sent copies of the booklet to all medical schools and designated institutional officials for free dissemination and is developing a companion slide presentation for use in a live didactic session — which ideally could be one module in a broader series on medical and legal issues, such as end-of-life decision making, conducting human-subjects research, grants management, and business operations.

Like it or not, billing and reimbursement have become integral parts of the practice of medicine. I hope that medical schools and residency programs will teach new physicians the fundamentals early, helping to ensure that they steer clear of fraud, waste, and abuse when they go into practice. The OIG and its law-enforcement partners have developed expertise in prosecuting health care providers for violating the fraud and abuse laws. Of course, we would all prefer that no violations occur in the first place. Enhanced physician education would represent a big step toward this goal.

The views expressed in this article are those of the author and do not necessarily reflect the official view of the Department of Health and Human Services or the Office of Inspector General.

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Category: Healthcare Reform
Tags: Physicians, Physicians Prevent