03/01/2011 07:21 am ET Updated May 25, 2011

Health Care Fraud: Who Is Responsible?

Every day, I sit down at my desk and reach for the stack of mail, magazines and "junk." After a while I develop a rhythm where, in one fluid movement, I can extract the slick advertisements and float them into the trash can next to my knee. The other day I had a steady rhythm going when my eyes locked on the bold red, white and blue flyer. It asked, "Can you imagine making a year's income in a month's time? Would you like to increase your weekly income by $8000-$10,000 dollars?" It was not from an investment firm, but was aimed at my medical practice. It announced seminars throughout the United States where I could learn how to get more money out of the worker's compensation system. All I had to do was take the course, buy their machine, follow their instructions on using the "correct" billing codes and I too could be driving a nicer car in six months.

Sound good? Payments from insurance companies have been decreasing, and who couldn't use a little extra cash in their pocket? Is this an unusual practice or is there a more pervasive problem?

Federal authorities recently announced a $225 million Medicare Bust on more than 100 doctors, nurses and therapists. A proctologist in Brooklyn, New York billed Medicare $6.5 million for hemorrhoid removals he never performed, while a physical therapy scam billed Medicare $57 million for back rubs. As large as these amounts of money seem, they barely make a dent in the size of Medicare and insurance fraud.

It's Not Just Medicare

The Coalition Against Insurance Fraud estimates that fraudulent claims and billing by health care professionals accounts for between $60-90 billion a year. Who is driving this fraud? Are doctors cloaking themselves in the sanctity of patient care and then pointing their finger at the other guy? The truth is that junk science, inappropriate testing and unnecessary procedures are being promoted by all of the different sectors of the health care pie. For example, a person may see their automobile accident as an opportunity to make money or a physician may order excessive tests in their office to make up for the reductions in what they get paid for their services. Fraud is around us in many different forms.

After an accident, the patient may be an innocent bystander who is being used by an unethical doctor or attorney to exaggerate their claim and billings. The physician or chiropractor may see the patient as a vehicle to perform more profitable tests, while their attorney wants to increase the tests in the case to increase its value. The unsuspecting patient may believe that he really needs all of the testing and as a result may develop a false belief system that he has a more serious problem. For example, normal wear and tear in the spine on an MRI scan is presented to the patient as "a serious problem that will never get better."

The medical provider may be driving the process by having the patient return for unnecessary testing and treatments. Just open the newspaper and look at the ads for a "free" initial evaluation. How many of these people are examined and told that everything is normal and there is no need to return? Once in the door, the testing and treatment begins and continues for far too long. A sting operation may catch patients, professionals and attorneys working together. People feign injury and are sent to a healthcare professional who will order numerous unnecessary tests and therapies, documenting injuries that don't exist. It's hard to believe, but it is not a rare occurrence. Remember the estimate of between $60-90 billion dollars a year in fraudulent claims?

As a physician this is difficult to write but, D.J. Osborne, who was with the National Insurance Crime Bureau until 1997 reported that, "This recipe is only about making money, not making people better ...The doctors following this recipe use their profession, position in society and our trust, to steal through costly exams, tests and treatments." He calls them "criminals, who happen to be doctors!""

Back and Neck Pain

No other group of symptoms is more vulnerable to unnecessary testing than neck and back pain. Very few people go through life without having episodes of low back and neck pain, but in the vast majority of these cases the pain is secondary to normal aging or a soft tissue injury in the muscles or ligaments -- not due to a herniated disc. This fact doesn't stop an expensive and unnecessary search for a "ruptured" disc, exposing the patient to unnecessary tests, treatments and surgeries.

The doctor should ask, "Will the test I am ordering alter my decision making process and my clinical management of this patient?" Unfortunately, the uninformed or unethical health care professional may proceed with unnecessary testing and in the worst case, surgery. The patient then develops a belief system that they have something much more serious than a self limiting soft tissue injury and they believe that their condition is permanent. Not only has the doctor ordered tests that the patient doesn't need, but he has "given" the patient a disease and a permanent disability. In many cases it isn't the accident that causes the disability, but the manner in which the person is treated by the health care professional.

It's Everyone's Problem

This is not just a problem for insurance companies. The cost trickles down through society and affects anyone who pays an automobile, home owner's or health insurance premium. I am not naïve enough to believe that if we eliminated fraud, insurance companies would reduce all of our premiums and increase physician reimbursement. The cynic in me tells me that corporate profits and CEO pay would increase. However, we do need to protect our patients from unnecessary testing and surgery that detracts from the high ethical standards of the medical professional. We have a responsibility to speak out.

Correction: We previously reported that D.J Osborne was with the National Insurance Crime Bureau. We've been informed that D.J. Osborne has not been associated with the National Insurance Crime Bureau since 1997 and he does not speak for the organization.