Most physicians have no idea the dangers that lurk when it comes to the problem of Medicare fraud. Every physician knows it is wrong to up code Medicare bills (intentionally or not). Most physicians know that each up code could result in a $10,000 fine, but most physicians do not think the problem will ever come to their door.
I can state with confidence that the topic of Medicare fraud is one that physicians need to start addressing due to the fact that the federal government has a task for specifically created to hunt down physicians that bill incorrectly. I have attended seminars given by other attorneys that have defended physicians after being "busted" for unintentionally up coding.
These federal task forces are a significant income generator for the federal government. Why? Because when a Medicare auditor comes to a medical practice and finds billing problems (that they always can), the auditor will threaten the physician with significant criminal penalties. In an effort to get out of the criminal penalties, physicians agree very quickly to pay sizable (several hundred thousand dollars per doctor) civil penalties in order to have the auditor not push the criminal case.
It's actually much worse than it sounds.
Do you trust your employees?
While we all think our employees making between $20,000-$75,000 a year are going to look out for our best interest, when a big reward is on the table, you would be surprised at how quickly an employee can turn against you.
I found the following on a website titled taxpayers against fraud where on the site they were discussing how every day citizens can benefit by turning in physicians that commit Medicare fraud.
"If the case (the Medicare Fraud case) results in a financial recovery by the government, the whistleblower receives a share, generally 16 to 17 percent, as a reward for revealing the fraud which otherwise might have gone undetected. Since 1986, more than $10 billion has been recovered for taxpayers under the federal FCA. Eleven states and the District of Columbia have enacted their own FCA's to protect state funded government programs."
The above paragraph lays out the classic way a physician loses a Medicare fraud case. The insurance and billing clerk is questioned/threatened by the federal agent investigating your up coding. The employee does not want to get in trouble and is told by the investigator that if the employee helps the investigation, the employee can receive a reward equaling approximately 17% of whatever the fines ends up being.
The employee starts doing the math and figures out that the bigger the fine the better. Then after fully cooperating with the federal agent, the fine ends up being $1,000,000. The physician does not have 1 million and has no insurance and therefore has to cash in his/her brokerage account or 401k plan to pay the fine (which is not tax deductible). The employee is black balled in town, but doesn't really care because she ended up with a reward of $170,000.
If the above scenario doesn't scare you, nothing will.
With all the potential problems of Medicare fraud, where does that leave physicians? Unfortunately like an ostrich with their heads in the sand or with the "it's not going to happen to me syndrome."