March 22, 2011, 4:25 pm

Fraud or Abuse? Either Way, No Pay

And the winner for Best Posture in a Student Nurse goes to…..

I wonder what they are doing here? It does look like they are all standing at attention.

I’ve been trying all day to think up hilarious dialog for this pic but nothing is coming to me. If you think of any, have at it in the comments. Of course, the minute I post this, I will think of a bazillion of them.

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Grand Rounds is up at Better Health!

I actually managed (barely!) to sneak in a post this week!

It is a fantastic edition with some new (to me) blogs and lots of old favorites, so grab a cup of coffee (the best way to enjoy the Rounds!) and check it out!

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We hear so much about health care fraud and how much it costs us all in terms of higher Medicaid, Medicare and private insurance costs, and if we could just rein in this fraud we could make our health care system pay for itself.

My trusty Mac widget dictionary defines fraud as:

  • a person or thing intended to deceive others, typically by unjustifiably claiming or being credited with accomplishments or qualities and
  • wrongful or criminal deception intended to result in financial or personal gain.

Well, I’m wondering, what is actually considered fraud?

Let me give some examples, and help me understand whether or not this is fraudulent behavior. The examples are purely hypothetical and do not represent any known individuals, living or dead, or specific situations in any known emergency department, living or dead.

  • A patient covered under Medicaid utilizes the emergency medical system by calling 911 for transport to an emergency department to obtain a refill for a non-emergent medication (ie, not insulin).

Fraud? If the patient does not claim an emergency problem, there is no deception, ergo no fraud. But if the Medics can’t triage this call out (aka, say “HELL, no!”), there is a $1000 ambulance bill and it’s at least $1000 to walk in the ER. The patient pays nothing. If this isn’t a fraudulent use of the EMS system, what do we call it, abuse? Abuse for personal gain?

  • A parent walks in to the emergency department with his eight children, all of whom are covered by Medicaid. He wants all eight children seen for colds. It is the middle of the day. The local pediatric clinic is open. It is ascertained that the clinic will see all the children later in the day. It is also ascertained that the father is aware that the cost of seeing the eight children will be one hundred times higher in the emergency department than in the clinic. The response is “I don’t care. I’m not paying for it.”

Fraud? Again, no claim of an emergent problem, so no fraud by definition. But the ED cannot, by law, turn the father and the children away, at least here in CA. So, if the cost of a clinic visit is $20 (for example) and the total visit for each child in the ED is $2000, that’s quite a bill that Medicaid now has to deal with. Again, if it’s not fraud, do we call it abuse for personal gain?

  • A patient covered by Medicaid utilizes the EMS system for transport, requesting a hospital quite a distance from where they live. The chief complaint given the paramedics is not the same complaint they state on arrival. The revised complaint would have required the medics to take them to the closest hospital. This is the fifteenth visit in four weeks. All by ambulance. Given the patient’s history and the chief complaint on arrival, most ED docs feel obligated to at least a minimal work-up. Multiple doses of narcotics are required. Lots of narcotics. Gallons of narcotics. Hour are spent. Disposition is always discharge.

Fraud? I’m calling yes on this one. Patient wants a specific facility, knows how to get there by not using an emergent symptom until arrival – that is deception, at least. It’s drug seeking, and drug seeking is fraud, hands down. But how do you prove it? In this example, the patient is racking up tens of thousands of dollars in medical bills on a weekly basis. The medics can’t refuse to transport the patient, the facility can’t refuse to see the patient (although slowing down on the narcotics might slow down on the visits, no?) It’s deception for personal gain – so a fraud vote for me.

  • Patient needs a procedure. It is not emergent. Patient is not dying. Patient is perfectly fine and stable pre-op. Procedure is actually scheduled. But in order for the private insurance company to cover the procedure, the patient must be admitted through the emergency department, and actually go to the procedure from the ED. So, a full triage is done. An IV is inserted. An ED charge goes on the books.

Fraud? Oh hell, yes. Would someone explain to me why this is not fraud? If you need a procedure, you go the normal route like everyone else. This pretending you had to come into the ED first is a bunch of bull***. Good thing I never see it (cough) because I sure as hell would have nothing to do with it.

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Now that I look over these examples, I see more abuse than I do actual fraud.

Either way, it is a ton of waste.

How do we stop it?

They don’t let us stop it on site. We cannot turn away non-emergencies. Medics cannot refuse to transport.

Look at fraud, yes, but do something about the abuse of the health care system, too.

There is no penalty for abusing the system.

In fact, I don’t think people even recognize that they are, in fact, abusing the system.

I think they see it as their right to use it as they see fit, no matter what the cost. It’s there to use to their convenience.

And it doesn’t matter if it’s Medicaid, Medicare or private insurance!

Until people stop seeing their healthcare as being provided for free, there is no incentive to use it efficiently.

When you don’t have to pay the Piper, you don’t care what tune he plays.

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8 Comments

  • NPs Save Lives
    NPs Save Lives

    March 22, 2011 at 4:36 pm

    In Florida, I think the ER has the right to refuse to treat a patient once it is established that it is not an emergency and are told to see their provider. I am available 24/7 on call and we have nurses who triage for me to keep patients from going to the ER unnecessarily. Does it work? Most times not, because the pt goes to the ER without calling the after hours. They claim that they didn’t know…yeah right…


  • Julie
    Julie

    March 24, 2011 at 9:41 am

    This is a massive problem and is the reason why General Pratitioners in the UK increasingly ‘front end’ ER departments here. The patient is triaged and then if it is something that should have been seen in a primary care type place they are seen, treated and sent away. No amount of education seems to help since you don’t need to plan, make an appointment or wait longer than the queue in the ER. Maybe you can come up with a solution and make that first million?


  • locums
    locums

    March 26, 2011 at 1:27 am

    Hmmmx NIce


  • [...] Kim at Emergiblog helps explain fraud and abuse in the medical setting. [...]


  • The EMT Spot » The March EMS Roundup
    The EMT Spot » The March EMS Roundup

    April 3, 2011 at 8:06 am

    [...] appropriate trauma facility. Emergiblog asked us to consider whether some patient presentations are fraud or abuse? Everyday EMS Tips pondered the use of a defibrillator on a patient with an impaled metal object. [...]


  • Efoghor Joseph Ezie
    Efoghor Joseph Ezie

    April 7, 2011 at 1:39 am

    That is just the nature of man. Everyone wants to manipulate the next person to his own advantage. People to want to get things and avoid paying the price.People want to be regarded for what they are not.
    The best thing everyone must learn is how to be sincere to your fellow men even if it would cost you something.
    People should be able to trust whatever you tell them because they know you to be an honest person.


  • nurseygurl
    nurseygurl

    April 25, 2011 at 10:33 am

    What happened to the QMP Fad?

    At times, qualified medical persons may medically screen non-emergent cases. If a qualified medical person determines that a patient?s medical condition is non-emergent and non-urgent upon completion of the medical screening exam, the following options will be represented to the patient:
    Stay to see the Emergency Department physician for care and treatment after being registered and paying the hospital and physician fees, for such medical care and treatment.
    Follow-up with a family physician.
    Seek medical care and treatment at a community clinic. A list of community resources will be attached for reference by the patient.


  • Eric
    Eric

    November 28, 2012 at 8:32 pm

    “…. the cost of seeing the eight children will be one hundred times higher in the emergency department than in the clinic.”

    “, there is a $1000 ambulance bill and it?s at least $1000 to walk in the ER. ”

    Right there is the REAL fraud and abuse. Those charges are insane. The entire medical industry needs to be revamped.


About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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