Fraud is defined as “wrongful or criminal deception intended to result in financial or personal gain.” And the U.S. health care non-system — really a dysfunctional phenomenon of market failure more than a system — is riddled with fraud.
Imagine having a doctor give you a $70 orthopedic boot for a foot injury only to turn around and receive a $30,000 bill — yes, that’s tens of thousands — for “surgery.” But that’s what Brooklyn journalist Kate Arnoff just had happen to her. Note the collusion of parasitic actors — few of which are actually providing health care — in her Twitter thread about the matter. Read it from start to finish.
I want to point out that it wasn’t Kate’s doctor defending this “surgery” bill, but instead the “billing company” employed by her doctor. A number of doctors and hospitals in the U.S. medical non-system now contract with companies whose sole reason for existence is to game the medical coding system in order to suck as much money as possible from patients. Case in point from a company called MediRevv:
In revenue cycle, payment posting and collections often take the starring role. After all, this is where the money comes in. But, the truth is, the champion of the revenue cycle often gets overlooked — that is, until there is a glaring problem.
In the new era of value-based reimbursements, never before has the process of medical coding had such a powerful impact on revenue cycle performance. Every stage of the healthcare revenue cycle has an impact on the next. This means that what begins as a small problem in one phase has the potential to mature into a costly setback further down the line.
Now, Kate is insured, but do you think her health insurance company really has an incentive to waste time and resources fighting this fraud? Hell no. They pay what they want to pay and then, if that leaves the patient left owing tens of thousands of dollars, and at risk of bankruptcy and destroyed credit — well, good luck.
So, is this an insurance company issue or a doctor issue? Well, it’s clearly not the insurance company demanding $30,000 from Kate, but it’s the insurance-based system that creates the “space” for this kind of fraudulent behavior by providers.
In a singe-payer, Medicare-for-all system, patients are not left in despair to mediate between an insurer whose goal is to spend as little as possible on care and a doctor or hospital whose goal — not all doctors! — is to earn as much money as possible. Rather, if the doctor tried to charge the government $30,000 for a freaking boot, they would be at serious risk of criminal prosecution — and the patient would not be forced to negotiate the crisis. The patient would either be responsible for a small fixed co-pay or nothing at all.
With a single-payer, Medicare-for-all system, patients would be relieved of the tremendous burden of being forced to personally combat financial fraud in the health care system, whether it results from overzealous coding by a provider or, in the example below, a health insurer fraudulently denying payment for something that no reasonable person could have predicted would have happened in advance, a miscarriage.
The “job” of patients in a moral and humane health care system should be to follow the directions of their doctors in order to achieve good health. It should not be to stumble through a barbaric financialized non-system of health care with rampant fraud and abuse.
The status quo of U.S. health care is a non-system driven be abuse, fraud and greed — there is a better way.
