register |  login
› PARKER
Loading Ad
Visit Other Hubs:
ADVERTISEMENT
Loading Tower
Blog
Blog Entry 6 of 7 HealthCare Confidential - An Insider's Guide to the Health Care Game.
Health Care Confidential provides an insider's unique perspective and commentary on one of the most visible and important issues in Colorado (and the country) today - the health care and health insurance industries. Over 25 years of professional insider knowledge and experience on how the "Health Care Game" works will be featured here. In summary, I have advanced degrees in Business Administration and Computer Information Systems and specialize in health care systems and consulting. I've worked on all sides (technical, business, provider) of private and governmment health care and health insurance systems. The ignorance of and assumptions made by mainstream media reporting (as well as other high-profile local and national spokespersons) regarding our health care and health insurance industries are astounding. Superficial reporting by people with no experience in the industry propogates the misinformation. At other times, the information is presented in a manner that makes makes most people want to faint from boredom and complexity. Want to know what happens to your insurance claim after you've seen your doctor? Want to know why "the rising cost of health care" is not a given fact, but is in fact a lie? Want to know all the ways doctors and hospitals cheat insurance companies? Want to know why all discussions about health care reform tend to concentrate on the insurance-side of the health care equation? HealthCare Confidential is the place to find out.

Blog Url: http://denver.yourhub.com/~HealthCareConfidential

Happens all the time, they just got caught.
Contributed by: Dave Schallert   on 3/31/2008

A perfect example of what really happens inside the sausage factory that is the Medicaid health insurance program is illustrated in this article ( http://www.rockymountainnews.com/news/2008/mar/31/guilty-plea-in-medicaid-fraud/) in today's (03/31/08) Rocky Mountain News.

Whether you want to believe it's true or not, this happens ALL THE TIME in Medicaid (and Medicare for that matter). This guy's problem is that he appears to have hit what we call the Variance Limits that exist in all computer systems that process Medicaid and Medicare health care claims from Providers (i.e., Doctors, Hospitals, and in this case DME (Durable Medical Equipment) vendors). He might also have fallen victim to Recipient Sampling.

Here is HealthCare Confidential's inside information on this topic that you likely won't hear or learn from any other source.

There are variance edits and audits within the computer systems that examine Medicaid (and other programs') health care claims. Should a Provider's billed charges ( how much they are asking for payment) or frequency of billed charges ( how often they are billing for similar procedures) or volume of billed charges ( how many procedures are being billed for in a single day) land outside of these system variances, those claims will be "suspended" for review and will subsequently be scrutinized by personnel within the Medicaid agency. In this case, the Provider would have been D&D Medical (Mr. Arnold's wheelchair repair company) and the procedures would have been coded on the claims as various kinds of DME/wheelchair repair.

It's also possible that someone whose wheelchair was supposedly repaired by D&D Medical was contacted in a sampling of Medicaid Recipients to verify that procedures billed by D&D Medical did in fact occur to the Recipient's wheelchair. These "samples" essentially seek to verify that something a Provider says they did really did occur. For example in D&D's case, it's possible they billed Medicaid for repairs to "Mary Smith's" wheelchair...and "Mary Smith" received something from Medicaid asking if D&D really had repaired her wheelchair on such-and-such a date. If "Mary Smith" knows this wasn't the case and contacts Medicaid, D&D Medical would have immediately come under extensive scrutiny as a Medicaid Provider. And it only takes "a flip of the switch" within the systems to monitor everything D&D Medical was billing from that point forward.

Had D&D Medical and Mr. Arnold just performed LESS fraud than they did, their chances of getting away with it would have been quite good.

This happens all the time folks. Show me a "poor" Medicaid provider and I'll show you someone who hasn't learned to cheat the system or is one of those very rare honest Medicaid providers who do the right thing.


SUBMIT COMMENT

Rate the above blog



Current Rating
Based on 2 user ratings.

Talk Back : submit comments to the blog

*Note: you need to log-in to add a comment or rating.

CONTRIBUTOR INFORMATION

Dave Schallert

Parker , CO

Dave Schallert has posted 7 blog entries and 2 comments since joining on 7/12/2007. Dave Schallert 's average blog rating is 4.71.
SAVE AND SHARE THIS BLOG ENTRY
BLOG ENTRY RSS FEEDS
BLOG LIST
WANT TO WRITE FOR YOURHUB.COM?
Want to see the stories you write and the photos you shoot featured in the YourHub.com Thursday print section available all over the Front Range and with home subscriptions of the Rocky Mountain News and The Denver Post? All you have to do is  register,  then post a story or column, start a blog or tell everyonewhat events are happening in town. We will print the best stories, columns, event listings, photos and blog entries in our print sections.

ADVERTISEMENT
Loading Ad

Loading Ad
ADVERTISEMENT
Loading Ad

This YourHub.com community is produced by The Denver Newspaper Agency
Web Development and Channel Analytics provided by Indigio

terms of use //  privacy policy
the staff //  advertise //  help & faq
buy photos