Medicare Abuse

Published

Medicare could save millions of dollars if they had a way to hotline medicare abuse. I wish I could pick up the phone and report the physicians who keep patients in the hospital sucking up resources because the patient (or family member) doesn't want to go home. (No medical necessity).

Or the frequent flyer who repeatedly gets admitted for phony ailments, gets their PCA for days on end and then gets discharged with no med changes or new diagnosis.

Or the "pulmonologist" who doesn't wean the vents for days for no reason, because he gets more $$ for an ICU visit.

I could go on, but you get the point.

Until physicians get paid one lump sum per DRG like hospitals, nothing will change.

I think hospitals should deny priveledges to physicians who suck the life out of our hospitals. :madface:

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Specializes in ICU, ER, HH, NICU, now FNP.

uhm...there *IS* a medicare fraud hotline.

However, unless you actually know it all - I'd be very careful about that. Obvious fraud should of course be reported.

Do you really think these folks actully get PAID? Sometimes they might - but I assure you - often times, they don't.

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Specializes in Education, FP, LNC, Forensics, ED, OB.
contacting the hhs oig hotline

by phone:

1-800-hhs-tips (1-800-447-8477)

by fax:

1-800-223-8164

by e-mail:

[email protected]

by tty:

1-800-377-4950

by mail:

office of inspector general

department of health and human services

attn: hotline

330 independence ave., sw

washington, dc 20201

http://oig.hhs.gov/hotline.html

http://www.cms.hhs.gov/apps/media/press/release.asp?counter=349

http://www.medicare.gov/fraudabuse/howtoreport.asp

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Specializes in Family Nurse Practitioner.

Its possible that I didn't get this second hand story correct but my impression is that a friend of a friend worked in a docs office that was charged with medicare fraud and the nurses were hauled into court also. I think that if they suspect that you knew something it can make you a defendent also. Feel free to correct me if someone knows that my details are wrong.

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Thanks for the links:

I know these are where you can report medicare FRAUD; I was talking about abuse/misuse of the system, which right now I think the government is WAY behind on picking up on this.

Haven't you thought to yourself, "geez, he/she really knows how to work the system"..........there's no precise LAW they're violating but it's still a dishonest way to get money/your way, technically.

Know what I mean?

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Specializes in Education, FP, LNC, Forensics, ED, OB.
Its possible that I didn't get this second hand story correct but my impression is that a friend of a friend worked in a docs office that was charged with medicare fraud and the nurses were hauled into court also. I think that if they suspect that you knew something it can make you a defendent also. Feel free to correct me if someone knows that my details are wrong.

You are correct, Jules A. Anyone involved in fraudulent practice can be named in the legal action. Nurses who know fraud is taking place and do nothing about it can be prosecuted for abuse of the system as well as fraud.

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Specializes in Education, FP, LNC, Forensics, ED, OB.
Thanks for the links:

I know these are where you can report medicare FRAUD; I was talking about abuse/misuse of the system, which right now I think the government is WAY behind on picking up on this.

Haven't you thought to yourself, "geez, he/she really knows how to work the system"..........there's no precise LAW they're violating but it's still a dishonest way to get money/your way, technically.

Know what I mean?

Anyone can report abuse of the system in the same place (links above).

Another link on fraud and abuse:

http://www.kansasmedicare.com/policy/fraud_bene.htm

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Specializes in Day Surgery/Infusion/ED.

And you can get nailed for Medicare fraud even if it's unintentional. One of the reasons why you absolutely must be sure pts. meet criteria for admission to hospice/home care. Squeaking pts. through because you think they should have the services may be kindhearted, but if the pts. don't truly meet the criteria, you're toast if Medicare audits charts and finds out.

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Specializes in ICU.

Please excuse me if I sound a little defensive here, but MD's don't get paid anymore for having a patient in house longer, and particullarly not for keeping them on the vent longer. Many times there is a single payment, and it would be the hospital that would be paid more for the patient staying longer. Beyond this, it is important to realize that physicians only get about 30% of what is billed (and in some cases, like IL, they aren't being paid for months on end, if at all), and thus loose money on some of those patients. Also, there are such mechanisms in place as Quality review, Clinical Review, and Utilization, that go through the charts everyday , both for the ho and the insurance, that prevent such things from happening. Medicare abuse would be billing for a service that wasn't performed, or billing for a physician consult, when only the nurse saw them, or so on.

And as for not being sent home bacause the family or patient wasn't feeling ready, the physician stands a greater chance of being sued if something were to happen, than if they would have just let the patient stay one extra night to make everyone feel a little more secure, which medicaid most likely won't pay them for anyway. Don't harpoon the MD's for a faulty system. Alright, I'll stop now. I've vented enough.:trout:

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Thanks, Siri, I wan't aware that medicare cared that the hospitals were getting screwed over prolonged lengths of stay.

We have Utilization management, but they have no teeth. Here, the Dr is still God. Nurses typically get blamed for "avoidable days". ("Why doesn't Mrs. X feel secure about going home? Is it something WE did or didn't do?")

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I used to see a lot of misuse of Medicare when I worled in the hospital...not really abuse, but misuse because people were admitted when they didn't need to be, came to the ER for everything from sniffles to wanting their toenails trimmed, and people wanting Medicare to pay for their toothpaste.

Now that I do LTC, I see something that appears to be quite to opposite. We have a man that just switched over from a private insurance to Medicare. He has been taking Ambien since it was a brand new drug and now all of a sudden, Medicare wants him to switch to Tylenol PM. We have a lady that had all sorts of cancer to her mouth and throat...it is really hard for her to eat because of sores, dentures that simply cannot fit properly, and problems with salivary glands causing her mouth to be very dry and Medicare doesn't want to pay for her supplements...she should be able to eat regular food...why should they pay for Magic Shakes and Boost? Even pureed food is hard for her to eat...they are always too thick and if they dilute them down, she needs to eat/drink a HUGE amount to get enough calories. It is to the point that employees and her family are paying for her supplements out of pocket...one lucky nurse just found a bunch at Wal-Mart that was about to expire and is 1/2 price.

Sometimes it seems like you just can't win.

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Specializes in Family Nurse Practitioner.

I also heard (ha, I'm a mecca of "not sure if its true" trivia) that the medicare costs in a persons last three months of life average about 75% of their entire medicare costs. I took that to mean that more procedures etc. are done prior to the person checking out which makes sense on one hand but on the other hand when I see a LTC pt that has been in a wheel chair for years die on the operating table during a hip replacement I just shake my head.

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