Boots On The Ground In The War Against Healthcare Fraud

Third party insurers paid each of these practitioners or facilities. They do not have enough personnel to look at time-of-day stamps. There is no way for a patient to retract benefits assigned before a procedure. The third party (payer) cannot audit the contents of the blue book. My college classmates asked in April, “Why do they do it?” The answer “because they can”. “Why do they do it?” Another answer “greed or laziness.” These practitioners received money; a high school student would receive an “F.”

Many healthcare providers and facilities are honest. The healthcare bureaucracy must empower the individual to be the final authenticator of the blue book written record of events. If the patient flags the record, the possibility of record fraud has to be taken seriously. “We don’t know” or “I have to trust my colleague” are not acceptable replies.

Only someone like me, who practiced medicine for 40 years, personally managed a practice for more than three years and sat on the hospital performance improvement board could begin to have navigated the adversarial HIPAA procedures in place at AMC. Accordingly, the patient who flags a record should be assigned an advocate.

Minutes of the state medical board, hospital accrediting agencies and institutional peer review committees are “not discoverable” in civil suits. In July 2016, the Atlanta Journal Constitution began publishing a series titled “License to Betray”. In this series doctor misconduct is sexual in nature. The failure of transparent accountability is identical to my experience as a victim of medical record fraud. The next patient is rarely able to know there is the possibility of unprofessional conduct by a given physician.

An empowered patient should assign third party (insurance) monetary benefits to a doctor or hospital only after completion of care and only after the patient has reviewed the text in the blue book.

If an empowered patient has reported unprofessional provider conduct to a government agency, there must be transparency. The transparency must extend not only to the outcome of an investigation but to the reason for the outcome. The explanation is no more or less difficult than that needed to obtain informed consent for invasive medical procedures. Patients can understand.

Empowerment of the individual requires legislation.

Knowledge empowers people.

1 thought on “Boots On The Ground In The War Against Healthcare Fraud”

  1. As I read through each of the posts dealing with the inaccurate / misleading / dishonest recording of what was supposed to be fact regarding a patient’s care, I am left to wonder how and why this appears to happens at so many different venues be they hospitals, clinics or physician practices. Is the mandating of electronic records making this worse? Once upon a time a physician could dictate notes as the patient was examined. I the patient could hear what was said and even ask questions to make sure I understood what was being said. That dictation was then transcribed into the legal record. No preset block to check off, no preset text to copy

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