After the arrest and prosecution of a medical billing company that helped customers work the system in Florida for years, the Washington Post proudly reported the discovery of fraud. The article by Carrie Johnson can be viewed at:
http://www.washingtonpost.com/wp-dyn/content/article/2008/06/12/
AR2008061203915.html?hpid=topnew
For purposes here, the issue of fraud is one that has been addressed regarding public and private health insurance, and health service providers.
While those against universal health care will argue it's a governmental problem and those for universal health care will argue that our continued ignoring the broken parts of Medicare is not a justification for dumping Medicare, there are some issues that are laid on the shoulders of consumers. Yup, it's our fault.
While the article talks about the "growing" problem of Medical fraud, fraud is not an unknown problem, you'd have to be living under a rock to believe that one. So how is this consumer fault? Because while we are nickel and diming our way to feeling powerful by supporting exclusions of various people from health insurance coverage and while we're happily contemplating how much money we'll put away TAX FREE (up to almost a whopping $6,000 per family) in health savings accounts, medical insurers and medical services providers are getting rich through traditional CAPITALIST thinking...when demand goes up, raise prices. Of course all this is coming to a head because people can no longer pay for the Mercedes of this medical biller any more than we can continue to pay for the Mercedes of a physician or a health insurance executive. Our solution has been to cower and suffer rather than demand change.
In no other field is the "I didn't know" excuse more effective than in fraud charges. There's a simple reason for that, fraud REQUIRES showing there was INTENT. Instead of trying to read the minds of those who rip off the sick and aging for profit, it's time to apply a strict liability for negligence standard to every party involved in these previously "unknown" scams. Negligence requires a different standard: Known or SHOULD HAVE KNOWN. Is there anyone who doesn't think that the health services industry and its payers shouldn't KNOW that there is rampant working of the system? We can no longer afford to buy the "I DIDN'T KNOW" excuse.
The trade off in trading the challenges of proving intent to achieve a criminal conviction for fraud is of course that you don't get a criminal conviction. But people CAN be fired for negligence, people CAN be fined for negligence, people can LOSE their authority to obtain a license to engage in a business for negligence.
There are some serious issues that arise from accepting the "I DIDN'T KNOW" excuse.
Gross incompetence on the job, negligence (an act OR OMISSION), is an easier standard to meet to get someone out of the money-bilking business because it carries only the stigma of being incompetent, not criminal.
1) Federal workers who take years to "discover" problems that are the purpose of their jobs SHOULD KNOW that such inaction results in the creation and exacerbation of such problems..that is NEGLIGENCE. That's why we write to the landlord to tell him about a broken step, it's called NOTICE.
2) We need more staff because we can't investigate everything...This might be relevant to issues being addressed BEFORE notice of a problem, not after. If you cannot do your job then you are admitting you can only sort of do your job, well, most people don't get to keep a job they can only sort of do. If the workload is too big for you, communicate it BEFORE there is an issue, cover yourself by evidencing what your job duties are that you can perform. Trying to excuse your negligence by arguing you were in over your head in terms of expertise or workload is negligence when you KNEW or SHOULD HAVE KNOWN that was the case. Federal workers should be fired if they admit that they only address 5% of fraud cases.
3) I relied on what I was told...this I don't know excuse will likely be used by the doctors and providers who were participants in the fraud. Under a negligence standard, who cares. You were part of this, you should have checked out someone who was acting as your agent, you are fined. This isn't harsh, if you buy something that is stolen you risk losing the item and the amount you paid for it, usually because the amount you paid is less than what the product would have ordinarily cost giving you a good indication it was hot. In the case of these medical services providers, if their names, their patients' names or their company names were used to obtain medical equipment it doesn't matter that they didn't notice the problem, they should have and they are responsible for financial reimbursement. If the provider argues he didn't know about the fraud, he certainly knew about the money he was getting and the records he has showing what is submitted from his office.
4) "Working the system": Why did you do it? Because I could. Stealing money from the sick and aging if it's done by gunpoint is a crime, if it's done over the internet is a "scam" if it's done by a corporations it's "BUSINESS?" Health insurance companies have NO INCENTIVE to clean up their acts. Health services providers have NO INCENTIVE to stop the abuses of the system through over-testing, over prescribing, over-billing and short-changing patients.
5)Budgeting through raising prices: How great would it be if we could say that the cost of gas has forced us to raise our salary requirements and effective in two weeks, we will be charging more for our services? Only governments and corporations and medical services providers have this freedom, the rest of us have to tighten our belts.
So instead of the glitzy "FRAUD" conviction and the self-congratulating employees who wave their little success in the face of the American people, how about a list of people who are fired, fined, de-licensed and barred from engaging in a business for which they are incompetent?
