Corruption in Healthcare: A Quick Glance at Overbilling

              In conversation with my optometrist regarding ethical concerns in healthcare, he encouraged me to explore instances where practitioners overbill government health care programs, such as Medicare. For background, I will explain the concept of overbilling as he explained to me. At the optometry office I work at, we have different billing codes for eye exams which range from Level 1-Level 5, depending essentially on if the patient is new or established and how much time the patient spends with the doctor. Level 1 may be where the patient never sees the doctor while Level 5 would be a much more severe and time-consuming case. The higher the level, the higher the price insurance reimburses the doctor. Overbilling here could be billing for a Level 4 exam when it was actually a Level 2 exam in order to earn more money.

               One example noted in ProPublica was Dr. Mark Roberts, a family practitioner in Alabama, who billed for the most complex and expensive type of visit 4,765 times a year (Ornstein & Grochowski, 2017). This amount was greater than any other U.S. doctor, providing him approximately $450,000 in revenue from Medicare (Ornstein & Grochowski, 2017). For comparison, he essentially billed at this rate 95% of the time while other family practitioners in Alabama only billed this code 5% of the time (Ornstein & Grochowski, 2017).

               Ornstein & Grochowski (2017) note this problem exists among numerous doctors: in 2012, 1,807 practitioners billed for the most expensive visits at least 90% of the time, while in 2015, 1,825 practitioners billed at this high level (Ornstein & Grochowski, 2017).  Dwayne Grant, the regional inspector general for evaluation and inspections in Atlanta, notes that while some physicians may truly only see the sickest patients who require these high-level services, it is unlikely all 1,800+ of these physicians are doing so (Ornstein & Grochowski, 2017). Alternatively, Cyndee Weston, the executive director of the American Medical Billing Association, notes that electronic medical record systems can automatically assign billing codes depending on doctor’s input, and the codes selected tend to be of higher cost (Ornstein & Grochowski, 2017).

               I think for most of us, it is clearly unethical for a practitioner to bill for services they did not provide for financial gain due to justice. While something should be changed to electronic records to prevent this, how should we handle these practitioners with poor ethical choices?
                

References:

Ornstein, C., & Grochowski, R. (2017, December 27). Some Doctors Still Billing Medicare for the Most Complicated, Expensive Office Visits. ProPublica. Retrieved from https://www.propublica.org/article/some-doctors-still-billing-medicare-for-the-most-complicated-expensive-office-visits