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Politics : A US National Health Care System? -- Ignore unavailable to you. Want to Upgrade?

To: Lane3 who wrote (10826)	10/28/2009 12:12:46 PM
From: i-node	2 Recommendations Read Replies (1) \| Respond to of 42652

The story focused on cases where parties who had no business operation were enrolled. That is low hanging fruit. Sure, you're not going to stop the doctor who makes a fraudulent claim for every twenty of legitimate ones that way. But you sure can stop medical equipment companies that don't exist. That is certainly feasible. Doctors are easy as they require licensure. While I agree, and previously stated, that if you can stop bogus enrollment it is a great thing to do. The problem is that making enrollment more difficult doesn't do that. All that is required for a medical equipment company to "exist" is for someone to file incorporation papers, apply for a federal tax id, and that's it. You don't need anything else. A smart scam artist can crank this stuff out like an assembly line, having 20 such entities ready to go if one is discovered. It isn't just medical equipment. State Medicaids have lost many millions to fraudulent non-emergency transportation claims. The most effective single thing to stop this fraud is a no-brainer. You put a phone number on the patient's copy of the EOB where it says, "IF YOU ARE CHARGED FOR ANYTHING YOU DIDN"T RECEIVE CALL THIS NUMBER AT ONCE." Then, have a human answering the number, and every call that comes in results in an audit of the DOS for proof of medical necessity, proper credentials of the biller, confirmation with the referring, etc. And if it is determined fraud occurred, you immediately shut down any further funds transfers to the provider. This is not complicated and would solve the problem. THE ENTIRE POINT OF MAILING AN EOB TO THE PATIENT IS TO HAVE A THIRD-PARTY CONFIRMATION OF THE EXPENDITURE. THERE IS NO OTHER REASON. Yet, these people have no ability to follow up on fraud reports as it is. I think a more complex enrollment process does little to solve the problem. But at the very least, when someone reports potential fraud as a result of the patient EOB, which is the only purpose for having the patient get a copy, then there is no excuse for it to continue. I have no problem with modifying the enrollment process to make it more effective in screening out fraudulent operators. But they already collect just about every piece of information one can imagine; I just don't know what they could do to improve the situation in this regard.