Posted and filed under Fraud, FWA, Healthcare.

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.

Explanation of Benefits (EOB).

Explanation of Medicare Benefits (EOMB).

For those of you in the fraud, waste, abuse (FWA) and compliance space, these two terms can send a chill down your spine.  As a well-versed former OIG agent, who worked in the trenches of FWA, every time someone hands me one of these horrible documents, or even worse, I have to read my own, I already know I am going to stare at it angrily, wonder how many trees were killed for no good reason, and toss it aside.  Now take that feeling of frustration as someone who is “in the know,” and give that same document to an 80-year old Medicare beneficiary.  If you have ever dealt directly with this population, and the EOMB/EOB that comes in the mail, you know it is going to be a good time.

I have often wondered why the EOMB/EOB is so scant on information.  The Current Procedure Terminology (CPT) descriptions have both a lay person and a technical definition.  For those of us who are not sure what a fluorescein angiography is, why would it not be in everyone’s best interest to just indicate on the EOMB/EOB that a test involving dye inserted into a vein and a series of pictures taken, like x-rays were administered?  If you read last week’s blog post, you will recall that I discussed an ophthalmologist who billed for this test and indicated that each patient either had the test repeated immediately on the same office visit, or had a third eye.  If the Medicare population saw that they all had a blind third eye, maybe there would have been more complaints, earlier on in the scheme.

The Medicare program generally includes a 20% co-payment due from the patient, after the program pays its 80% share based on the fee schedule (there are some caveats to this, as some laboratory tests are covered at 100% of the fee schedule, and deductibles for the year will apply).  The point of this co-payment, among other things, is to give the patient “skin in the game.”  If there is a financial attachment to the item, service or procure, one would think there would be a higher level of scrutiny placed on those amounts due.  We do it with absolutely everything else we receive invoices for, yet we tend to argue a lot less about that 20%.

There is a slew of discussions that can be had over co-payment waivers, but the point is, unfortunately, that the scrutiny we place on things that directly affect us, we do not do with our EOMB/EOB reviews.  This is particularly the case with instances where there is no co-payment (either by a lawful waiver, kickback waiver, or because of a secondary insurance that covers those co-payments).  I know that even with a complicated EOMB/EOB, if I saw that a provider submitted a claim for tests that I could understand, or even simpler, an office visit that was for more time than I saw the provider, I would understand that much more than some five-digit code and a barely understandable description.  Again, I am in the know on these things, so take this to the Medicare beneficiary who has absolutely no idea.

Sometimes I think that we in the healthcare FWA space, and in the payer space, just do not know how to get out of our own way.  The process is complicated enough, and the one area where I have always thought there was a way to make it a bit simpler, was to “dumb down” those pesky EOMB/EOBs.

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.