Tuesday, May 25, 2010

Medicare Fraud

By Brian Kopp, DPM

Podiatry Today
August 2001 •

In my first week of podiatry school, one young professor stood before our freshman class giving his first lecture. He began by saying, “Podiatry is what I do. It is not what I am. What I am is a husband, and a father, and a believer.” It is the only direct quote I remember from eight years of schooling and two years of residency, and when I keep this hierarchy of priorities, life goes well.

During our early years, we lived in an apartment above our office. Patients got to know my wife and three young children, and continue to bring cards and gifts for birthdays and holidays. My training failed to prepare me for the depth and scope of the friendships I would form with many patients, or the very real sense of loss felt when patients passed away. The personal (if not financial) rewards of the practice of podiatry have far surpassed any preconceptions I had when I started my practice.

Unfortunately, all my years of training failed to prepare me for another reality of podiatry. Recently, I read a discussion on an online podiatry e-mail list about the perception that there is a federal “witch hunt” going on regarding fraud among podiatrists.

Yet daily I see evidence of the fraud the feds maintain exists, as patients come to my office after having seen other podiatrists. They uniformly expect that their routine foot care will be covered, because it always was before.

As I review their medical histories and find no qualifying systemic diseases, and find strong pulses and healthy skin, I go into what has become a standard monologue:

“Cutting toenails and trimming corns and calluses is called routine foot care. Medicare simply does not cover routine foot care unless the patient has an underlying disease that would make it dangerous for them or a family member or friend to care for them. Your feet are healthy and you have none of the underlying diseases, and you say you don’t have pain in your toes from the toenails. Therefore, unfortunately, this will be a noncovered service. You may bring back your EOMB from your previous doctor’s visit, and I can review it with you to see if there’s some way I can get your treatment covered too.”

After reviewing numerous past EOMBs with my patients and discussing this issue with peers around the country, I’ve come to the conclusion that the feds are not unjustified. Podiatry seems to be blind to the scope of insurance fraud rampant among our ranks. Here are some common examples:

• billing 11721 when there are only one or two mycotic nails, or, as often as not, no mycotic nails;
• reporting pain or infection where there is none;
• claiming PVD where there is no clinical evidence;
• class findings grasped out of thin air;
• billing 11721 or 11720 when 11719 is clearly the appropriate code;
• billing 11730 when no such procedure was done;
• billing for ulcers or skin neoplasms where only corns and calluses exist;
• billing the 11055-11057 procedures in conjunction with 11720/11721/11719 on patients with underlying systemic diseases where no corns/calluses existed;
• practices that bill routine foot care as covered in 100% of patients, or bill E&M codes instead when routine foot care is provided;
• unnecessary surgical procedures, such as the patient presenting with a simple, uncomplicated ingrown hallux nail who was previously told this was secondary to a very mild bunion deformity that would first need correction to resolve the onychocryptosis.

Medicare fraud is easy to rationalize (i.e., “Medicare guidelines and reimbursements are unreasonable,” “procedural definitions are unreasonable,” “managed care is taking away our patient base,” “our bottom line is constantly shrinking,” etc.) Given the entitlement mentality of the retirement population, who demand that every conceivable medical treatment be covered, I’m seen as the bad guy and the fellow who fudges it to get it covered is the hero.

Of course, these things are rationalizations, not justifications, for fraud, which is never justifiable. The government defines the regulations and terms under which we work and get reimbursed. They may be grossly unfair. Lobbying to effect change for the better is the duty of all disagreeing with these regulations. Committing fraud to circumvent them is unethical and criminal, and the feds would be guilty of wrongdoing in the utilization of my tax dollars if they failed to investigate and eliminate it.

Fraud investigation is also the only hope I have to practice on a level playing field. Maybe my religious convictions engender a certain scrupulosity over ethical billing practices. I know that if I’m ever forced out of the practice of podiatry, it will not be due to managed care, Medicare restrictions/cutbacks, or educational loans and malpractice costs. It will be because I cannot and will not compete with those—too common in our ranks—who say, “Podiatry is what I do, a Medicare fraud is what I am.”

Dr. Kopp has been in private practice since 1995 in Johnstown, PA. He is a regular contributor to several national Catholic periodicals, writing on issues of morals and ethics.