Medicare fraud vs error


Margaret talks about Medicare fraud vs error as it often comes up and is a legitimate concern.

The difference between error and fraud is the intention, which is difficult to prove. When it comes to our nation’s medical billing scheme, the misuse – whatever the intention – is far too prevalent.

When it comes to speeding, it is irrelevant that you didn’t intend to speed, speeding is still not tolerated. Why? Because the stakes are too high. If you get caught speeding, you will get a speeding ticket and if you keep doing it you may lose your licence – you may even end up in jail.

Speeding is what we call a strict liability offence and that is what is needed when it comes to persistent Medicare misbilling. This isn’t about one-off odd-looking bills, it is about patterns of concerning behaviour that need further investigation.

If we had a properly policed and enforced, strict liability system in place, we would quickly see the ‘error’ rate decrease, just as we did when speeding cameras became commonplace. And where there is genuine room for the misinterpretation of codes, this must also be corrected.

This would be much less stressful for healthcare professionals than the current investigation systems in place. Rather than going through years of investigation under the Professional Services Review Agency process, it would become a simple fine and correction. It could even include a penalty points system just – as we have on our driving licences.

Medicare belongs to us all, and the system needs to change so that misuse (whether intentional or not) does not break a system already buckling under pressure.

Dr Margaret Faux (PhD) – Founder & Chief Executive Officer
Synapse Medical Services


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