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Wednesday, April 21, 2010

An Example of Medicare Fraud

 At the hospital staff meeting yesterday, we discussed at length a claim that Medicare is trying to deny paying the hospital. Here are the facts:

1. A patient was admitted from the ER with an admitting diagnosis of: "Acute eexacerbation of COPD (Chronic Obstructive Pulmonary Disease)".
2. The ER doctor wrote the admission orders on a pre-printed order form titled, "Pneumonia Admission Orders". We have several pre-printed forms for different conditions. We have these to remind us to cover all the "quality control" items mandated by Medicare.
3. While the patient was in the hospital and after further testing, it was determined that the patient indeed had pneumonia.
4. The patient was treated appropriately for pneumonia, had an uneventful recovery, and was discharged.
5. The final diagnosis was PNEUMONIA and Medicare was billed for this.

Now Medicare is denying the claim and only wants to pay the hospital for "exacerbation of COPD" a lesser diagnosis which pays less. Medicare says that the ER doctor made an error by entering a COPD diagnosis on the pneumonia admission orders. If the ER doctors had used the generic admission orders, everything would have been fine.

Now the fact of the matter is that the treatment for a COPD exacerbation is more or less the same as it is for pneumonia. The ER doctor used the pneumonia form because it ordered the exact same tests and drugs that he would use if he had written the orders out manually on the generic form.

Now to my knowledge there is no requirement by Medicare or any other gubment agency that admission orders be written on any pre-printed form. By denying this claim to our hospital, they are just making up the rules as they go along.

I have heard Barack and the crooks in congress blabber on endlessly about evil doctors and hospitals and how much we engage in Medicare fraud in attempts to fleece the taxpayers.

After reading my little story, I ask you, "Who is committing the fraud here?"

The hospital will appeal this decision, but it will be a crap shoot of we get paid the proper amount, and then think of the time and money soaked up by the appeals process.

Boys and girls, doctors and hospitals have to deal with this pure unadulterated gubment BS fraud each and every day, and it is destined to get worse unless Obamacare is repealed. I'm glad I'm getting older and hopefully won't have to work much longer.

4 comments:

  1. Perhaps the doctors need to start giving diagnoses like "COPD exacerbation, rule out pneumonia, rule out (fill in the blank)...

    Debbie
    Right Truth
    http://www.righttruth.typepad.com

    ReplyDelete
  2. Sorry toots, "rule out" has not been an "allowed" diagnosis for a very long time now.

    ReplyDelete
  3. I think this type of thing is often what happens with "take backs": not an intentional over billing or trying to get something for nothing, but just a paperwork kerfuffle. A legitimate service is provided but the contracted insurer does not end up paying a dime for it. Where has the Supreme Court been on all this?

    ReplyDelete
  4. I think this type of thing is often what happens with "take backs": not an intentional over billing or trying to get something for nothing, but just a paperwork kerfuffle. A legitimate service is provided but the contracted insurer does not end up paying a dime for it. Where has the Supreme Court been on all this?

    ReplyDelete