Muddying the waters on Medicare fraud


Increasingly, as federal efforts to cut down on excess Medicare spending get more frantic, the line between outright fraud (billing to shoe people who had their feet amputated) and administrative problems (applying the wrong code to a procedure) is getting blurred in public discourse.

Take a recent report from the feds asserting that the government paid out more than $47 billion in questionable Medicare claims during 2008. If correct, that would suggest that waste and fraud had jumped to a rate three times as high as the previous year, according to a wire service reporter covering the issue.

Then, the news story goes on to note that this may be a bogus number. Much of the increase, the story goes on to note, is attributable to a change in HHS methodology which imposes stricter documentation rules and includes more improper payments. The headline for this story: "Report details billions lost in Medicare fraud."

While the headline is technically accurate, policymakers who skim headlines may not take in the fact that much of the jump in questionable billions was created by HHS itself. And since the piece appears in The Washington Post, policymakers on the Hill are more than likely to use it as ammunition.

Another example is the bill filed by Senator Chuck Grassley (D-Iowa), which proposes to freeze Medicare payments that could be fraudulent, abusive or wasteful. While we all understand what Sen. Grassley is getting at here, lumping in waste with fraud and abuse implies that all three concerns can be addressed in a simple, straightforward manner.

At minimum, one-size-fits-all remedies for waste could hinder the process of finding actual criminals. At worst, it could devolve into a useless discussion of battling standards. Until we institute nationally-accepted comparative effectiveness standards, or otherwise form a consensus on effective approaches, such efforts simply agitate without saving real dollars.

I could go on, but I'm sure you get the point. As long as discussions of fraud and abuse are framed carelessly, or manipulated to force through legislation--including reform--the Medicare program is at grave risk. Cutting out cancers makes sense, but you have to know where to cut. - Anne

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