ATLANTA — Depending on what political party you ask, the dollar amount associated with Medicare fraud is different and has estimates that reach as high as $80 billion. On Thursday, attendees of the Healthcare Information and Management Systems Society (HIMSS; Chicago) annual meeting had the figure put into perspective by CNN's Senior Medical Correspondent, Sanjay Gupta, MD, and Harry Markopolos, the fraud investigator that exposed the ponzi scheme of Bernard Madoff.
Markopolos told the audience that every year of Medicare fraud is equal to $60 billion, or the amount of money bilked off unsuspecting victims in Madoff's ponzi scheme. He added that up to 20% of all Medicare expenditures are fraudulent.
Gupta interviewed Markopolos regarding healthcare fraud, subtly weaving in and out of the topic of Wall Street fraud – showing how the two were similar at times and also very different.
Markopolos said that Medicare fraud is easier to get away with and that healthcare fraud is a whole lot more serious than Wall Street because not only is money at stake but so are “lives.“
He said that the most common frauds are upcoding – which involves a physician treating a patient for a disease like pneumonia and submitting a billing claim that the patient was treated for complex pneumonia.
Other types of fraud occur through kick-backs for medical devices and pharmaceuticals.
Markopolos urged attendees not to take anything from vendors – whether it is a coffee mug or lunch, because studies show those gifts influence the way physicians make their purchases.
He also said that a good rule of thumb is to ask the question who benefits from this purchase from the vendor – the physician or the patient?
“Think of it as if you're a homeowner,“ Markopolos said. “If a painter paints your house, does he cut you a check after the work is done? When you're treating patients financially instead of clinically, the government will put you in an orange jumpsuit.“
Gupta asked why fraud was so rampant especially when it came to the Centers for Medicare & Medicaid Services (CMS).
“Are they not good at their jobs or are they overwhelmed ...?“ Gupta asked Markopolos.
Markopolos said that in some instances that the answers to both of Gupta's questions are yes. He added that organizations like CMS become “captive“ of the industries they regulate. He pointed out that this is the case with FDA too, which sometimes approves medical devices and pharmaceuticals they shouldn't.
“It happens because CMS is [underfunding enforcement] and the returns to [commit] the fraud are so high,“ Markopolos said. “When the cop on the beat is asleep this is a problem, but when he's comatose that's an even bigger problem and that's the case with CMS.“
He added that Electronic Health Records (EHR) put a different spin on fraud and serve as a “double edged-sword“ in some respects.
“The EHR can make fraud easier to find, but also makes it easier to camouflage.“
Gupta brought up recent comments made by Sen. Tom Coburn (R-Okla.), who said that the government should send undercover patients into doctors' offices to probe whether the doctors were willing to break Medicare rules — a practice that would be highly similar to mystery shoppers that help identify bad customer service at stores.
“I'm curious is that where we've arrived ... undercover agents?“ Gupta asked.
Markopolos said that while this was an effective tool, as a citizen of the U.S. it felt a little too “big brotherish.“
“It's a proven law enforcement tool,“ he told Gupta and the audience. “I hate to say it, but it may come to that.“
But Markopolos said that healthcare had gotten into a rut and that the seriousness of fraud and healthcare spending is getting to the point where it needs some type of stricter regulation.
“That's a result of the industry not healing itself,“ he said. “Now healthcare is going to have an outsider come in and do it for them. “We're now 16% of GDP we're headed toward 20%. Medicare looks like it's going to go out in 2017 [or] 2019. We have two choices; go bankrupt as a country or we get government spending and healthcare spending under control.“
Gupta's interview of Markopolos helped close nearly four days worth of activities and sessions geared toward health information technology last week.
The key take home message from this year's meeting was that the group can be the attendees of change. The message of change ranged from being leaders in innovation that would help initiate stronger healthcare reform to not turning a blind eye to any type of healthcare fraud.
In an earlier session, HIMSS board Chairman Harry Chaiken told the audience to continue to stay the course and that their contributions would help transform healthcare.
“It's now about what you and your organization are doing to transform American healthcare,“ he said. “I suspect that some of you may see yourselves clearly within this context while others may not. Let me suggest to you today that no matter whom you are and what your role is, you have an important, if not critical, role to play to achieve transformation. You can fulfill your role by building a multidisciplinary team with the expertise needed to solve a problem. You can fulfill your role by gathering and sharing data and evidence as you go along. And you can fulfill your role by having the courage to stay the course or to change your mind – whatever the situation calls for.“
Omar Ford 404-262-5546;