How to Commit Medicare Fraud: Procedures and Prescribing

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By R Carter

In recent posts on Medicare’s new opioid prescription policy I was critical of the policy in general due to its close alignment with CDC guidelines on chronic pain management. I still believe the CDC guidelines are inappropriate and flawed because the data and guidelines are geared towards opiate naive patients, not chronic pain patients.

Over Prescribing or Something Else?

The Office of Inspector General released a brief July 2017 addressing opiate abuse through Medicare. An updated report, titled “06-27-2018 Report (OEI-02-18-00220)” was released June 2018 and had the key points below.

  • Nearly one in three Part D beneficiaries received a prescription opioid in 2017.
  • Overall Part D spending for opioids decreased, due in part to declining prices.
  • Almost 460,000 beneficiaries received high amounts of opioids in 2017, fewer than in 2016.
  • About 71,000 beneficiaries are at serious risk of opioid misuse or overdose, also fewer than in 2016.
  • Almost 300 prescribers had questionable opioid prescribing for the 71,000 beneficiaries at serious risk.
  • The high level of opioid use continues to call for the public and private sectors to work together to address this crisis.

In the PDF link at the top of the page, are examples given where one patient collected over 3,000 tablets in a month. I have doubts that such an occurrence is the results of a physician actually writing scripts. Its more likely the scripts are falsified via electronic means. Still such occurrences feed into the data collected inflating estimates on actual prescriptions written per patient. At present there doesn’t seem to be any means to filter out such data from national statistics.

While there’s been no significant improvement at reducing this type of prescription fraud, it’s clear that this is bad not just for the public in tax dollars but also for the chronic pain community. If the wide spread knee-jerk response of the anti-opiate message continues, the lack of research funding for chronic pain will result in additional regulations based on opiate naive patient data. Clearly the NIH needs to fund research on the long term effects of opiates in chronic non-cancer pain, as well as eliminate the type of fraud seen above.

Medicare beneficiaries who suspect or have knowledge of fraud can follow this link to report what they know under the Federal Whistler Blower act.

Procedural Fee Padding

Billing for plausibly related procedures which require little or no effort and may or may not get performed is called, padding your fees. It’s a method of gaining more reimbursement revenue for essentially doing nothing or next to it. As someone with first hand experience on treatment methods and procedures, any testimony I provide on a fraud report should be treated as insider information, or at least well vetted. But that’s not what happened when I reported a case of fraud to Medicare as I explain in the examples below.

Personal Experience

As a former anesthesia provider I have good insight into standards of care, practice guidelines and procedures. I filed a complaint on a former prescriber, Leon Margolin of Comprehensive Pain Management in Columbus Ohio, after reviewing the EOB’s from Medicare and finding at least one procedure charge on every office visit and sometimes as many as three, which were billed fraudulently or were highly questionable.

Such activity in the profession is called, padding your fees. It’s a method of gaining more reimbursement revenue for essentially doing nothing or next to it. As a former anesthesia provider, someone with first hand experience on treatment methods and procedures, any testimony I provide should be treated as insider information, or at least well vetted testimony. But that is not what happened as I explain in the examples below.

  • Billing CPT Code 76942 – Ultrasonic guidance imaging supervision and interpretation for insertion of needle
    • Billed amount $400.00, Medicare pays $58.43
    • The code states that the practitioner used an ultra sound device to guide the needle during insertion. The purpose is to prevent damaging a nerve by stabbing it with the needle.
    • In my case the provider never used ultra sound on any injection, yet he billed for the procedure.
  • Billing CPT Code 64450 – Injection Of Anesthetic Agent, Other Peripheral Nerve Or Branch, AKA a trigger point injection.
    • At Comprehensive Pain Management this code was always billed in conjunction with the previous code.
    • Billed amount $440.00, Medicare paid $115.90.
    • So how would a patient know if a doctor is injecting a medication close to a specific nerve? When done properly a patient will feel some discomfort which radiates into other parts of their body, beyond the local injection site.
    • If you get repeated trigger point injections and never have this experience, there’s a good chance the procedure is being done incorrectly and you’ll not likely get the benefits it’s designed to provide.
    • In the 14 months I saw Dr. Margolin, after more than a dozen injections, not once did I get the benefits intended.
    • When I pointed this out to the doctor, the response I got was, “I think you are getting a benefit, you just don’t know it”. In psychiatric circles this kind of statement is called “Mind F–king”.
    • Any doctor who responds with answers like this, is lying to you. Find a new doctor.
  • Billing CPT Code 96127 – Brief emotional or behavioral assessment.
    • Billed amount $20.00 Medicare pays $6.00.
    • These links explain to doctors how to use this code to pad a claim for addition revenue. This link as well.
    • As the code does not allow billing time associated with the activity, providers usually use a computer to ask questions and collect answers or a paper form.
    • My provider used a paper form.
    • Such efforts are most often fruitless, unless a patient is mentally impaired. The questions are so obvious that a 10 year old would have no problem misleading the provider with a lie.
    • The manner in which it is used assumes the provider actually reads the responses and plans care around them. In my 16 years as a patient, I’ve given a variety of answers, sometime expressing a suicidal ideation, which should initiate a more detailed examination, yet not once has there been further investigation into the answers I provided.
  • So why do such easily defeated procedures exist?
    • They are part of a concept known as evidence based treatment. A method of collecting information to ensure that treatment procedures and goals actually have outcomes which can be measured, regardless of whether it was beneficial or not.
    • But as anyone with any common sense can see, if the provider does not participate by actually acting on the information collected, then the evidence is worthless and the procedure becomes a loophole for milking insurance companies of revenue.
  • Another form of fraud is billing a similar procedure code, when there are variations to chose from, which have a higher reimbursement rate than the actual procedure performed.
  • CPT Code G0397 – Alcohol And/Or Substance (Other Than Tobacco) Abuse Structured Assessment (E.G., Audit > 30 min)
    • Billed amount $130.00 Medicare paid $69.62.
    • This code requires the provider to spend a minimum of 30 minutes, face to face with the patient, performing this assessment.
    • Medicare allows billing this procedure once every 30 days.
    • At Comprehensive Pain Management a provider, either the doctor himself or a advance nurse practitioner, was never in an exam room longer than 5 minutes. I was also never asked anything more than, how are you doing. So at this clinic, billing this code was a clear effort to defraud Medicare.
  • CPT Code J3301 – Injection, Triamcinolone Acetonide, Not Otherwise Specified, 10 Mg
    • Billed amount $120.00 Medicare paid $15.16.
    • This code is also combined with 64450 and 76942. Triamcinolone Acetonide is a steroid given to reduce inflammation. It’s based on the assumption that inflammation is a contributing element of pain.
    • 10 mg injected locally by this provider, when normal amounts are 30-40 mg, should be enough to provide improvement for 3 to 5 days, if pain is in fact aggravated by inflammation. If there’s no improvement after 2-3 injections, continuing this procedure is unlikely to benefit the patient.
    • At Comprehensive Pain Management the policy is to continue steroids regardless of failed improvement. As such it becomes a means of padding fees for revenue.
  • CPM continued to bill these codes despite feedback that I was getting no benefit from them. These procedures were done between September 2017 and September 2018.
    • After documenting each incident where these codes were billed as either unnecessary or not performed, I contacted Medicare and reported it, requesting an investigation of claims.
    • Medicare offered to keep me anonymous to prevent retaliation from the provider and I accepted.
    • I stressed to Medicare that as a former anesthesia provider, contacting the provider would result in denials and any documentation provided would match the claims billed. For that reason they needed to observe actions not paper forms to confirm.
  • I received a letter from Medicare 40 days later stating this:
    • They had contacted the provider, given my name and requested my records, despite the fact that I asked not to be identified.
    • They found no discrepancies between the billing records provided and the claims filed.
    • Therefore their assessment was that no fraud had been committed.
  • Shortly after this, the provider discharged me from his practice. He waited until the day before my next visit to inform me, knowing that doing so would strand me without medication and without a referral to another provider. In Ohio you can’t get into a pain specialist without a referral. This is a clear effort of retaliation, something Medicare was supposed to protect me from.
  • This is remarkable.
    • After ensuring me I would not be identified by name, I was.
    • After stressing that they would receive falsified billing records, they accepted those records without further investigation.
    • After stressing that the practices of this clinic were wide spread and I had confirmed similar experiences from other patients, Medicare made no effort to investigate these claims for multiple patients.

For all the effort Medicare makes to identify fraud, their investigative methods suck. If this is how they conduct fraud investigations is it any wonder there are individuals out there getting 3,000 plus pain pills a month with Medicare picking up the tab.

Having followed Medicare’s recommended procedures I neither got results and in fact experienced retaliatory action from the provider. Given this type of results, I turn to this blog to inform others of the failures within this agency.

Maybe its time for someone higher up the ladder of authority to take a hard look at Medicare practices on investigating fraud complaints. I would write my congressman but in a conservative state, I doubt I would get any results and would likely experience more retaliation.



1 thought on “How to Commit Medicare Fraud: Procedures and Prescribing

  1. Thank You R. Carter,

    They have gotten really creative with the billing, and always maximize it. It seems really likely that certain providers are retaliating against patients that file complaints. They will even go to great lengths to “lose” their medical records and imaging. It is really terrifying what is going on. CMS does not investigate complaints, billing issues, or even faulty devices. The FDA covered up for the device industry, allowing the surgeons who allowed salespeople in the ER to blame the patients for the failing devices. It is positively Orwellian, how badly the medical, insurance and pharma industries are taking advantage of Medicare, and the patients.

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