Healthcare Fraud: DOJ is at the Door, but Providers Still Face a Measurement Problem in Medicine

The Department of Justice today announced what it calls the largest healthcare fraud takedown in U.S. history. It alleges that $900 million in false Medicare billing was committed by 301 clinical professionals.
It won’t be the last such sweep. As a historically inefficient industry fraught with risk, the healthcare industry is easy picking for government regulators and the Office of Inspector General. This week brought yet another addition to the writing already on the wall: BDO predicts that this week’s False Claims Act SCOTUS decision will have an outsized impact on the healthcare industry.
One of the major problems is, and will continue to be, the validity of the measurements that are increasingly tied to healthcare reimbursement by Medicare and by commercial insurers. Lacking a system of protocols such as Generally Accepted Accounting Principles (GAAP), healthcare continues to face a measurement validation challenge at the same time both fraud prosecution, the temptation to commit fraud, the potential to unintentionally commit fraud, and data complexity are all increasing.
“There is a greater level of fraud in reporting this data than anyone wants to acknowledge,” Dr. David Friend, The Center’s chief transformation officer, told Hospital Peer Review in June.
“In healthcare, a lot of quality metrics are self-reported on some level, and those measures are less reliable than objective measures. It may be unintentional or intentional, but sometimes the numbers don’t you tell you the way it really is. That is why we have accountants who do audits and why we have the Internal Revenue Service to check your numbers instead of just taking your word that they’re accurate.”
Read the full “Self-Reported Data May Be Inaccurate” article, which published June 14, in Hospital Peer Review, and watch for an alert from The BDO Center for Healthcare Excellence & Innovation on the Supreme Court decision and its implications for healthcare providers.