The flickering vintage television partially illuminated the darkened room. –The image on the screen an instantly recognizable, Johnny Carson in Swami garb – turban and robe covered with stars and crescentic moons – the great Carsoni! The scene in medias res – spasms of laughter from the audience: an “answer” posed to Carsoni by Ed McMahon, followed by the Swami divining the question that best fits the provided answer. “Next answer” commands the Swami. “Fraud and abuse” offers the straight man. “What does the government perpetrate on physicians and the practice of medicine” intones the Swami. Laughter floods the room until a man seated in the front row – obviously a physician because he wears a white coat with real cloth buttons – shouts “that’s not funny because it’s the truth.”
I awoke from the dream thinking about the impending deadline for this column. Well perhaps the government was not committing fraud – a deception used to obtain unlawful or unfair gain, but abuse of the American health system was the kernel of truth contained in the dream.
All-fronts Attack
The interaction between medicine and government has become increasingly hostile. There appears to have been a purposeful effort, predominantly on the part of the executive branch of the federal government, to challenge and thereby change the field of medicine by a more aggressive, confrontational and seemingly abusive manner than experienced in the past. Purported reasons for these governmental actions include such diverse initiatives as “the public good,” “balanced budget” and “fraud and abuse.”
Some assert that the government’s fraud and abuse program is merely a way of enhancing federal income by inducing the health profession to not submit bills or to undercode to avoid audit. Conflicting with this perception is the fact that the Medicare fee-for-service program made $12.6 billion in overpayments for inappropriate billing last year and Physician at Teaching Hospital (PATH) audits have continued to be settled with large payments to the government. The success of these federal programs has encouraged state agencies and the private sector to increase their anti-fraud initiatives.
While the pervasiveness of the so called “fraud fighter” is on the increase, the total number of criminal convictions for health care fraud was only 303 for 1999 (40 of which were physician convictions).
More chilling was the 461,975 calls received in 1999 on the Office of the Inspector General (OIG) fraud hotline. Only 2.6 percent of the calls, however, resulted in complaints against providers. The majority were simply seeking information or resources. Calling this a “fraud and abuse” hotline is provocative and inflammatory and it should have a different name.
Neurosurgeons are not exempt from this hostile milieu. However, putatively illegal or unethical practices such as up-coding, unbundling and inappropriate/ unnecessary treatment become more understandable when it is recognized that these so called fraudulent acts are frequently based on differing opinions between the physicians rendering the service and the auditor’s interpretation of the provided level of service guided by Medicare Evaluations and Management (E&M) documentation guidelines. The challenge of documentation is made more difficult by the lack of an easily applied, concise system that accurately reflects the complexity of the decision-making process.
Preemptive Action by Neurosurgeons
It is my personal perspective that the aphorism “knowledge is power” has great meaning in this context. Neurosurgeons can be preemptive in avoiding miscoding by better understanding this unwieldy system. Beyond these obvious self-help initiatives, neurosurgeons should be aware that organized neurosurgery also is being preemptive in reducing neurosurgeons fraud and abuse risks. For example, the AANS has begun to sponsor a program for fraud insurance. In addition, the AANS/CNS Washington Committee supported the successful appointment of Troy M. Tiippet, MD (a member of the Washington Committee), to the AMA E&M Task Force. Dr. Tippett will not only represent neurosurgery’s interests, but bring a rational, common sense approach to an area of major contention with HCFA.
The flickering television depicted an image of the U.S. President. He was dressed as a Swami. In medias res – the answer had already been posed – “Senior citizens at doctors’ offices with tape recorders and stopwatches?” The audience was poised on the edge of their seats for the impending humor of the question to be devined – “What is the next step in the government’s attack against medical fraud and abuse?” The entire audience laughed hysterically, including the man in the white coat with knotted cloth buttons.