Posted and filed under Coding, Fraud, FWA, Healthcare, Medical Record Auditing.

Retired OIG Special Agent and Advize’s Director of Litigation & FWA Support will be stepping in each week to examine current fraud trends from the lens of an investigator. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

 This past week, while having lunch with a friend who knew about my background, I was asked why healthcare providers commit so much fraud.  My friend, who works as a local law enforcement officer (of course most of friends are in law enforcement in some way or another, having met many from my career at the OIG, and as a long-time Brazilian Jiu Jitsu practitioner), had a difficult time understanding how in a profession where high amounts of money are possible, there is so much fraud.

Of course I could have gone into a deep theoretical discussion with him (and consequently with all those reading this) about inherent greed, social norms in the healthcare profession, sociological theories of crime (operant shaping, differential association, and the like (if you check my LinkedIn profile, you will see I have a Master of Science in Criminal Justice, but it was really more of a Sociology based education).  Instead, I took the position of discussing with him the basic economics of the issue, and of course, the ease at which it can be committed.

I started out with the premise that locks are on doors to keep honest people out.  A true criminal will circumvent the procedures in place to stop the commission of a crime.  A locked door just keeps the casual criminal from moving deeper into the behavior.  Simple edits and standard fraud, waste and abuse tactics do not stop the true healthcare fraud criminal.  Those who are unscrupulous providers in the system have a slew of tools, tricks and schemes in their arsenal to perpetuate the commission of the crime; thus defeating the locked door.

I also discussed the fact that from an economic perspective, the system itself has, to an extent, triggered the increase in maybe not so much the fraud, but certainly the waste and abuses of the reimbursement system.  Providers work to provide defensive medicine, so as to insulate themselves from malpractice lawsuits.  A litany of unnecessary tests performed and billed may appear to those in the fraud, waste and abuse world as just that, but to a provider who is nervous about malpractice, the additional tests are that “belt and suspenders” approach to ensuring that malpractice suits are kept at bay.

Increasing overhead costs in a world where reimbursement rates are flat, can provide an environment where a provider has to make up that revenue to ensure the lights are on, staff are employed, and the practice continues to exist.  I am not advocating that any of these “justifications” are appropriate.  Keep in mind, I am having an open dialogue with a local law enforcement officer who deals with traditional crimes, and the motivation can sometimes be a but more apparent (the drug addict who needs to steal to get their fix).

My simple take away from the conversation was that although everyone agrees that healthcare fraud is a huge problem, sometimes people who read or hear about it, just do not understand the why.  From our perspective, we see it as merely greed to take advantage of a very damaged system.  To the unscrupulous provider, it may be a justification of behavior that is inconsistent with social norms when viewed as an outsider to the community committing the fraud.

If you are an unscrupulous provider, are you commiserating with your peers about how bad reimbursements are, and that keeping your practice operational is more difficult?  Are you the provider who is commiserating about not being able to make your Bentley payments because Medicare is tightening the rules under which you can bill for certain services that had previously been a cash cow for you?  Everything is a situation.

Advize Health LLC is a healthcare advisory and consulting company that provides a breadth of healthcare industry services in the payer, provider, and legal communities. Contact Eric Rubenstein for more information on our Fraud Spotlight series.