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Lying to Medicare about Diagnostic Results: Go Directly to Jail. Do Not Pass Go. Do Not Collect Reimbursement.

Posted on: October 15th, 2013

By: William Ezzell

Physicians practicing under Medicare may soon be reminded, “ignorance is bliss.” The evolution of medical technology has undoubtedly aided in the ability to diagnose conditions with greater certainty, and notably, increased detail. Yet, in an industry largely based on third-party payers and federal regulation, the increased knowledge new technology brings is potentially catastrophic.

As discussed here, the Department of Justice recently agreed to a plea agreement with a cardiologist where the physician is now serving a prison term of thirty to thirty-seven months. The cardiologist, working for St. Joseph’s Hospital in London, Kentucky treated a patient for an arterial blockage. The cardiologist reviewed the angiogram (imagery showing blockages in blood vessels around the heart), and noted a lesion in an artery as 70% blocked. Problem was, while there was indeed a block, the blockage was actually far less and the cardiologist was aware of this fact. However, if the cardiologist documented the blockage according to its actual level, Medicare would not have deemed the corrective procedure as “medically necessary” and would thus have denied reimbursement.

The cardiologist at St. Joseph’s is not alone – two other cardiologists suffered similar fates for the kind of conduct, and this problem is not limited to cardiology. As highlighted by the article, oncology could be next. Physicians want to try everything to beat cancer, and physicians often find success for certain patients when deviating from standard chemotherapy protocols. Physicians and hospitals be aware: altering the actual chemotherapy orders in order to ensure Medicare coverage has and can result in prison. The issue creates a moral dilemma that may be irreconcilable. However, at a minimum, this cautionary tale affords hospitals and physicians notice. Medical professionals must be aware of these potential traps, and should consult with counsel to establish appropriate courses of action

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