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Medical fraud – what to look out for

I was reading a news story about how medical fraud is becoming more frequent in Australia. They attribute this to the recent transition to electronic record keeping, which makes it easier to file fraudulent claims. Although these tactics are old news in the US, I think it’s worth a little summary (from the article) here – stay on the lookout for overcharges and fraud! The best way to protect yourself is to review your bills with vigilance. It’s sad that it has come to this…

Fraudulent tactics

Supply companies:

* Upcoding of items and services where, for example, a medical supplier may deliver to the patient a manually propelled wheelchair but bill the patient’s health fund for a more expensive, motorized wheelchair, or where a routine follow-up doctor’s office visit might be billed as an initial or comprehensive visit.

* Billing for medical services or items that are in excess of the patient’s actual needs. These might include a medical supply company delivering and billing for 30 wound care kits per week for a nursing home patient who only requires one change of dressings per day, or conducting daily medical office visits when monthly office visits are adequate.

Providers:

* Duplicate claims, where a certain item or service is claimed twice. In this scheme, an exact copy of the claim need not be filed a second time. Rather, the provider usually changes part of the claim so the health insurer does not realize it is a duplicate.

* Unbundling, where bills are submitted in a fragmented fashion so as to maximize reimbursement for tests or procedures that are required to be billed together at a reduced cost.

* Kickbacks, when a healthcare provider or other person engages in an illegal kickback for the referral of a patient for healthcare services that may be paid for by Medicare.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Humorous interlude about health insurance…

I’m doing my best to prepare my weekly round up of the best of Revolution’s expert blogs… but it’s taking a little longer than usual, so here’s a funny little excerpt from a Dave Barry calendar to tide you over…

In the 1950s, medical paperwork was simple: The doctor gave you a bill. That was it. Whereas today, if you get involved with the medical care system in any way, you will spend the rest of your life wading through baffling statements from insurance companies. I speak with authority here. At some point in the past, some member of my family apparently received medical care, and now every day, rain or shine, my employer’s insurance company sends me at least one letter, comically titled, EXPLANATION OF BENEFITS. It’s covered with numbers indicating my in-network, out-of-pocket deductible; my out-of-network, nondeductible pocketable; my semi-pocketed, nonworkable, indestructible Donald Duckable, and so on. What am I supposed to DO with this information?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Good news for celiac disease sufferers – biopsies may not be necessary for diagnosis

In a recent study published in the British Medical Journal, researchers found that blood tests and a history of patient symptoms might be all that’s needed to diagnose the majority of individuals with celiac disease. Until now, a diagnosis required a biopsy of the intestinal wall.

It is estimated that celiac disease (caused by an autoimmune reaction to wheat gluten) remains undiagnosed in a whopping 85% of cases. This may be due to the fact that symptoms are often non-specific (diarrhea and constipation, fatigue, anemia, tooth enamel defects, weight loss, and dry skin are some of the symptoms).

The researchers report:

We devised and evaluated a clinical decision tool that used a combination of pre-endoscopy serological testing (for tissue transglutaminase antibodies) and assessment of symptoms to identify patients with coeliac disease. This decision tool might help increase the detection of coeliac disease in patients attending for gastroscopy without the need to perform routine duodenal biopsy.

As efforts are underway to increase awareness in the primary care community about the disease, it is good to know that diagnosis may no longer require an invasive test!

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Herbal Remedy May Reduce Urinary Tract Infections?

The number one Google news item today is a report of a mouse study (published in Nature Medicine, but apparently still embargoed to the public as it is not listed on their website) that suggested that an herbal supplement could (in combination with antibiotics) “eradicate” urinary tract infections.

In usual fashion, the buzz preceded the science, and now we have thousands of people on the lookout for forskolin (a root extract of coleus) tablets from the local health food store. Do these have any possible merit?

A recent review of the literature about this herb was conducted by the good docs at Harvard, and turned up “no conclusive evidence for its [forskolin’s] use for any health condition.”

My friend Dr. Charles also read the reports of this “miraculous” new cure – which posits that recurrent urinary tract infections are caused by pockets of bacteria that hide inside bladder walls. Dr. Charles rightly points out that there are many different points of entry for bacteria, and that an herb which (and we don’t know that it even does this) relaxes bladder walls would surely not affect the alternate routes of entry, hence it cannot be curative in all cases.

So my friends, I’m sorry to say that there is little justification for enthusiasm yet. But we will follow the research with interest, in case human subjects do indeed show benefit in the future.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Made in America: The Institute of Medicine

I had dinner with a small group of people recently – and Harvey Fineberg, President of the Institute of Medicine, was our dinner speaker. A few things struck me as he reviewed the history of this 37 year old institution.

First of all, The British Medical Journal published a thought-provoking article about the top 5 things that Britain and the US could learn from one another’s healthcare systems. Of all the possible things that they could highlight about US Healthcare, the Institute of Medicine was listed in the #1 slot.

Well, my goodness – is that the very best of what US medicine has to offer? The IOM?

Maybe so. Here’s the Reader’s Digest version (forgive me Dr. Fineberg) of the history and purpose of the IOM.

President Lincoln founded the National Academy of Sciences back in 1863 for the purpose of advising the public in an objective manner on matters of science.  The NAS has expanded to include 3 newer organizations: the National Research Council (1916), the National Academy of Engineering (1964), and  the Institute of Medicine (1970).

The IOM consists of members elected by peers in recognition of distinguished achievement in their respective fields. It has about 1,200 members. But here’s why this organization is so unique: all of the members VOLUNTEER their time! Can you imagine another organization that could get 1,200 doctors to work for free? Yes, they volunteer – and they do so gladly because it is an honor to be part of the task force to advise the public in an objective manner on matters of medicine. The IOM gets no money from the government, it survives on donations and volunteerism.

The IOM is uniquely positioned to formulate unbiased assessments of important medical questions. It is medicine in its purest form – the facts and the data are the only foundation of their analyses. No government funding, no pharmaceutical intervention, no personal agendas. Just the pursuit of truth.

Apparently the IOM produces 1 report per week! The most famous of which may be their “To Err Is Human” (2000) report which uncovered the shocking frequency of medical errors, and included recommendations for new patient safety initiatives.

A lesser known report actually debunked lie detector tests…

And so, as I considered Dr. Fineberg’s description of the IOM I began to realize why other industrialized nations are jealous of our institute. I am so glad that President Lincoln had the foresight to create an objective, “collective wisdom” vehicle for advising the nation. The question now becomes: does the nation hear what they’re saying?

I think it would be wonderful for the IOM to allow Revolution Health to be an outlet for disseminating their information to the public. After all, our mission is to empower consumers with the most credible health information available… and my friends, after hearing Dr. Fineberg’s speech, I don’t think it gets any better than the IOM.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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