Virtually every year, the OIG, the Office of the Inspector General and the Department of Human Services, releases their report on recommendations to reduce healthcare fraud. It is a noble effort that comes out of unethical behaviors that attack the myriad of federal healthcare facilities. The goal of the comprehensive report is to enable providers to focus on compliance.
The complexities of healthcare make the deepest of deep jungles in the Amazon basin appear desert-like. The report is well meaning, well-intentioned and, of course, attempts to save the government money by reducing scams constantly perpetrated against the system.
In case you weren’t looking, Medicare and Medicaid are scammed out of billions on an annual basis.
New Recommendations
This year’s report lists 25 recommendations partly in response to the ever-changing scam landscape. It should surprise none of us that fraud related to COVID-19 had a major impact. We have reported on many clinics, nursing homes, and healthcare workers who were all involved in these scams. Another area that has sadly increased is elder abuse and hospice complaints and fraud.
It always amazes me as to how fraudsters and their staffs have no compunction when it comes to abusing the most vulnerable in our society. Also, no surprise is the healthcare frauds committed against those who are poor, single and isolated, non-English speaking or unable to read and comprehend.
We must keep in mind that to a fraudster, even one who owns a healthcare facility or clinic, there is no differentiation between the length of a stay and treatment and/or the quality of treatment. To a fraudster, there is no improvement of treatment if the course of treatment goes on for weeks – or longer.
The OIG has issued 25 recommendations for 2022 alone. Some are complex and quite technical, but to establish a pattern, let me comment and paraphrase on just five of them:
- Ensure nursing homes are implementing actions to better prevent the spread of COVID.
- Stronger measures to report potential abuse or neglect of Medicare and Medicaid patients.
- Taking stronger actions to ensure Medicare hospice payments are better tied to the needs and quality of care of the facility.
- The recovery of overpayments in situations where patients were severely malnourished to inpatient hospital claims.
- Better analyzing of charges for durable medical equipment.
Where are the Ethics?
As I sifted through the jargon and acronyms, it became clear that each point, each recommendation, distilled down and honed in on the same issue: ethical behavior – and the lack of it that pervades the system.
The contentious issues between Medicare, Medicaid and the healthcare facilities, the treatment of our most vulnerable by indifferent staff members, the poor quality of care in presumably the richest country on earth, is a study in fraud, a myriad of scams and in many cases, catastrophic patient outcomes.
Each case of fraud in this vast complexity of the healthcare system is a study of what occurs when money and an overall lack of ethical expectations permeates the system. I realize there are no easy answers, but I am also aware that in the 25 points of recommendations issued by the Office of the Inspector General and the Department of Human Services, the word “ethics” is not mentioned once.
If this entire process is “just” about money and payments, what does it say about the healthcare system? The game played between providers and payers, accomplishes little, and the fact that every year a new list of recommendations is spewed out of Washington, D.C., seems proof that the system is not working for anyone.
Why not emphasize ethics as the top priority in healthcare? Why not demand more training, seminars and meetings on ethics? Why not more certifications and lesson plans on ethics? I guess I am asking, “What does the healthcare industry have to lose?”
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