Over the years, I have periodically addressed the issue of fraud in vestibular testing. Addressing it only periodically doesn’t mean it isn’t happening every day, and the impact on patient care is going to be with us for a long time. There have been some recent high profile convictions related to millions of dollars of vestibular testing fraud. It’s about time. Or maybe it is too late.
In a post from 2011, I discussed some clear indications of potential fraudulent billing. According to the Medicare database, there had been a 1400% increase in the utilization of the code for rotational chair testing. The primary provider of these services was primary care/internal medicine specialists that did not even have the proper equipment to perform this test. Subsequently, Medicare made a coding change that reduced the reimbursement by 75% for those practitioners legitimately performing rotational chair testing. For more details about this, click here.
About four years ago, I was contacted by a fraud investigator for a large insurance provider that followed Medicare guidelines. She had seen my previous post and had some questions about a pain clinic billing for rotational chair testing. I knew the specific pain clinic and knew they did not have a rotational chair. When I told the investigator this was a widespread issue, she asked if I would be willing to speak to a group of fraud investigators at an upcoming meeting. I agreed, and dates were arranged. As we discussed my presentation further, I explained how I felt fraud investigators were part of the problem.
I explained that the problem, from my perspective, is that insurance companies think they can stop fraud by changing coding language, or changing a coding rule. When they see a spike in utilization, or a manipulation of a loophole in the coding language, they make an adjustment to decrease utilization or close the loophole. Here’s the problem with that: Who is going to strictly adhere to changes in coding language that negatively affects their bottom line? My guess is that it will be the people that were already following the rules, trying to function in an ethical and legal manner. Who is going to ignore or manipulate the new rule? Most likely, the same people that were abusing the old rule.
My message to the investigator was that to deter fraud, you have to go out and find the abusers, convict them, drop them as providers, or whatever it takes to penalize them for the fraudulent activity. When you keep restricting legitimate practitioners and lowering reimbursement below sustainable levels, you create an environment where only the abusers can survive. I made the point that their approach discouraged good care, and would eventually limit access to qualified providers. A week later, I got a call dis-inviting me to speak at the upcoming meeting.
In the second part of this post, I will discuss some cases of fraud that have resulted in recent convictions with substantial penalties.