With all the Advize bigwigs in Dallas this week at the NHCAA shindig, I am left alone to ponder my thoughts and wonder who I must have pleased not to have to schlep to Big D.
As per usual, one of the things I pondered was whether there were any new, earth-shattering trends in the healthcare fraud arena. One place to look for them is the DOJ website. This site has a collection of press releases that can be perused. Being the lazy sort (my bosses are away), I, instead, looked in-house to our own Advize newsletter from 11/3/23.
This newsletter does research for you and pulls out some of the newsworthy highlights. And what were the highlights this week? Two kickback cases and two patient abuse cases.
New? No. Earth-shattering? No. Disheartening? Yes. Horrific? Absolutely.
I have been in the FWA business since 1989. One of my first cases was a kickback case. A spin-off of that case was a patient abuse matter. Since that time, I have worked on dozens of both types of cases and have ‘witnessed’ hundreds more. The Medicare anti-kickback statute has been on the books for decades. I don’t know how many providers have been deterred by it, but I do know that the number of kickback cases has not decreased. I do not know the deep-seated reasons for paying/accepting the kickbacks, but I can say that the possibility of profit does compromise the healthcare decisions being made. The unnecessary (and sometimes invasive and dangerous) procedures that result from kickbacks are disheartening to see and go to the heart of the mission of anyone fighting healthcare fraud, waste, and abuse.
The only thing worse (perhaps) is patient abuse and neglect cases. While traditional program integrity investigators are not focused on these issues, when they see them, they act quickly to get them to the right entities – licensing boards, law enforcement, state agencies, and Quality Improvement Organizations. These cases go beyond fraud and strike at the heart of the practice of medicine. Again, I cannot fathom the rationale, but to see cases like this in the headlines week after week is horrific. To identify and help resolve such matters is a praiseworthy accomplishment that is on a different sphere than a simple financial fraud case.
So, what’s the lesson? Sometimes to hunt for fraud, you must retrace the same game trails you have tracked before. Always look for the newest trends, but don’t forget to keep your eyes open for the signs of familiar game. No matter how many have been caught, their numbers never seem to go down.
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