Healthcare fraud – Another example

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By R Carter

Our healthcare system is broken, driven by too much bureaucracy, too many hands in the bucket, greed, with so many loopholes, is it any wonder some patients spend years trying to pay off medical debts. Or worse yet, declaring bankruptcy or committing murder and suicide following an illness or injury, because they can’t payoff the bills. The tragedy which befalls these individuals and their families is a daily occurrence, which sometimes gets its fifteen minutes in the spotlight, only to be quickly forgotten as the system churns through its next set of victims.

It’s often difficult to assign blame in such occurrences, simply because there’s so many layers and so many hands, each trying to grab as much as they can before someone else beats them to the limited amount of cash a patient has before it dries up.

While most providers rely on benefits paid by insurance, some in healthcare don’t and in doing so cross a line, exploiting the elderly and infirmed, if not with incompetent practices then with predatory tactics designed to pressure and exploit honest and responsible individuals. Some patients are not able to recognize such tactics because our third party payment system is a nightmare of special terms and conditions that would take a team of lawyers to unravel and make sense of. Who can afford that? So many patients simply pay or don’t pay, never taking the time to unravel the mystery which explains what they are responsible for and what they are not.

In this post I will document one such set of events which were used to pressure a patient into paying for services which should have been billed to Medicare but were not. Instead, the patient was billed directly, the full rate for services some of which, when examined closely, were fraudulent to begin with.

The patient in question was injured and needed emergency surgery, has Medicare benefits and a top of the line Medicare supplement. As such, any provider who accepts assignment of these benefits would get paid per the Medicare rate schedule and the patient would pay nothing having all services covered by their Medicare and supplemental insurance.

How the system works:

Upon admission to a hospital a patient provides proof of insurance which gets them in the door for receiving services. Most practitioners who practice at a facility obtain the same information from the facility for billing their services. If a provider does not accept assignment of benefits, they are required by law to make arrangements with the patient for how they will be paid. This has to be done prior to rendering services, it’s part of the “informed consent” process. And if the patient refuses services from the provider because they don’t accept assignment of benefits, then in an urgent care situation, it is the responsibility of the attending physician and the facility to aid the patient in finding a provider who does accept assignment of benefits. Keeping in mind that the patient is in need of urgent care, they are not capable of shopping around for a provider, doing so will likely result in complications, damages or some cases death.

For providers who don’t accept assignment, this is a loophole, one they can exploit because of the bureaucracy of the system, the lack of oversight for provider services and the urgent nature of the patients need. In this instance, the provider provides services but never provides “informed consent”, the patient never sees the individual who provides care and knows nothing about them until they are billed for services.

Further obscuring the nature of this deception the provider uses a third party billing service to handle collection of their fees, in doing so they add another layer or bureaucracy,  further distancing themselves from the fraud they are committing. The third party billing service assumes the provider has done their due diligence in providing “informed consent” and usually has no way of confirming this. Billing services have become big business, are essentially unregulated and a primary source of insurance fraud because they provide another layer of anonymity for crooks and legitimate providers who are billing for services not actually provided. As in this case where a Texas personal trainer, applied for a Medicare provider number as a physician and was granted one because Medicare does not verify credentials of providers. Consequently the individual billed Medicare, Atena and UnitedHealth for millions before he was caught.

Experts estimate that fraud consumes about 10 percent of the country’s $3.5 trillion health care tab although the my efforts have found that large swaths of fraud which are not being tracked as the one sighted below. Those losses are eventually passed on to the public in the form of higher monthly premiums and out-of-pocket costs as well as reduced benefits.

The second part of the fraud is the billing codes used in billing for services, again the billing service has no knowledge on whether or not the services were rendered according to federal standards, they accept in good faith that the provider is submitting accurate charges. Figures 1 and 2 show three CPT codes submitted to a billing service which are both reasonable and proper for the type of services the patient required, with one exception, each code has a required time component as part of the charge.

Figure 1 – Page 1 detailed charges by provider


Figure 2 – Page 2 detailed charges by provider

In each case the CPT code used has a time component which the provider must adhere to in order to bill for the service. CPT code 99309, used by a physician, requires the provider to spend a minimum of 25 minutes face to face with the patient, taking a medical history and performing an exam, a 3rd qualifier sets the level of care required by the exam, in this case, from a patient with a significant medical problem. The charge for such service, $180.00.

The second CPT code 99305 is for non-physician providers, either a Physician Assistant or Advanced Nurse Practitioner, but similar to the code used by the physician, it too has a time component requiring the provider to spend a minimum of 35 minutes face to face with the patient taking a history and performing an exam, the charge for this service, $260.00.

The third CPT code 99316 is used when discharging a patient from a facility, it too requires a face to face visit from either the attending physician, Physician Assistant or Advanced Nurse Practitioner. This is where the provider gives the patient instructions to follow during their convalescence at home. The charge for this service, $210.00.

For the patient who was billed all of these charges, the total came to $830.00, yet at no time was there a face to face encounter with the providers, nor did the providers take a medical history or perform an exam. The providers may have reviewed the patient’s chart and medical history from the facility where the patient was transferred, we’ll never know, but this is insufficient for meeting federal standards of care in billing these services. Furthermore, because the patient never had a face to face encounter with these providers, there was no “informed consent” letting the patient know whether or not the provider accepted assignment of benefits.

The patient was discharged from the physical rehab facility sometime around January 21, 2019, subsequent to that, the patient received no invoice or statement from these providers for these services. It wasn’t until June 2019 that the patient received an invoice for services from the third party biller, seen here in Figure 3.

Figure 3 – Invoice for services without details on services rendered

Upon receiving this invoice, the patient reviewed the Explanation of Benefits (EOB) as instructed on the invoice, from their insurance provider and found that no claims had been filed on their insurance policy by the biller. They contacted the third party biller and requested a detail explanation of charges, which are shown in Figures 1 and 2.

After reviewing the detailed charges and seeing that the account was listed as self-pay, the patient contacted the biller and asked if a claim had been filed with Medicare. The biller said that they had not, since no insurance information was provided to the biller. The patient provided proof of insurance coverage. Subsequently, within a week the patient was contacted by the biller and informed that the account had been turned to collection and no claim could be filed. The biller asked the patient to contact the insurance provider to clear up the matter but said that it was too late to stop the account from collections. Both of these statements are incorrect and neither are the responsibility of the patient.

Within three weeks of receiving the invoice from the biller around June 29, 2019, the patient received a bill from the collection agency for the reduced amount of $180.00, no explanation has been given for this so it is assumed it represents some portion of the original charges which were not covered by Medicare.


Figure 4 – First collection notice

Since the patient’s insurance ensures that providers will be paid in full per the Medicare rate schedule, the patient followed up, checking Medicare EOBs and found that the three charges as listed on the detailed printout of the account, had subsequently been paid in full by Medicare and the Medicare Supplemental insurance sometime in July 2019. 

Had the patient followed the original instructions of the biller and collection agency, then insurance would have paid the claim and the patient would have paid the collector, inessence paying for services which per contact with the provider, are covered by Medicare. To further underscore the haphazard way this system operates, the patient contacted Medicare informing them about the CPT codes billed and the fact that the patient never had any contact with the providers for the services they claim to have provided. 

Medicare investigated only to report that the services billed matched the records provided by the biller. The fact that the patient states categorically that they never had contact with the providers and the services billed were never rendered, seems to make no difference at all to Medicare. They simply pay out on demand like ringing up a sale on a cash register, cha-ching!

And despite the fact that biller has been paid in full, the patient continues to receive demands for payment from the collection agency.

Figure 5 – Second collection notice

The patient went on to share with me that this is the 3rd time they have reported billing fraud to Medicare by a provider. In another situation, an anesthesia provider billed a high charge for a procedure on the patients shoulder when in fact it was the patients elbow which had been operated on. A third provider was reported for 21 counts of billing procedures which were never rendered in a clinic, only to have Medicare dismiss the report because the charges submitted match records in the patient’s chart. The fact that providers can falsify records, claiming to have provided services when in fact they have not, seems to make no difference to the Department of Health and Human Services.

So how broken do things have to get before our government takes action? This is just one patient. In 2009 there were 48 million surgical procedures performed in the US, this does not include procedures performed in physician clinics and labs around the country. Given the haphazard way HHS verifies procedure charges and their unwillingness to accept patient complaints as fact or make any other effort to confirm the accuracy of medical records, taxpayers are paying for billions of dollars in fraudulent claims each year.


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