Undercover Patients for Medicare Fraud Investigations?

coburn_c_200dpi_Thumbnail.jpgU.S. Senator Tom Coburn of Oklahoma, who is also a medical doctor, is proposing that the United States root out Medicare Fraud through the use of undercover patients. Actually this is not new a new idea, government agents have in the past used undercover activities for precisely this purpose; recently, undercover agents posing as patients have been used extensively for investigations of pain management clinics.
Part of the problem is that often the undercover agent has to come up with a malady that would be the pretense of the visit. Generally, undercover agents posing as patients generate a false identity as well as a false medical history; sometimes going as far as to use test results, x-rays or the like from other, real patients. Sometimes, for example with pain clinics, the condition could be somewhat subjective; “My back hurts.” Such investigations can have good, bad and sometimes even funny results. In one undercover investigation, a Medicaid fraud agent, posing as a patient going to physician’s offices where it was alleged patients were paid, learned that one of the physicians he went to see diagnosed him with, among other things, erectile dysfunction. On the not so funny side, one department of insurance agent investigating chiropractors posed as a patient and wound up receiving an adjustment that injured his back.
In the Medicare arena, since the program is for persons over 65, the challenge would be to use retired or near retired agents and then address the same quandary; do you falsify conditions or symptoms? This can be more difficult to do with an older agent/patient; some conditions or diagnoses that might lend to potential fraudulent activity by physicians such as cancer and cardiac conditions are difficult to fake. Although scenarios can always be found to avoid a circumstance where a patient will receive certain treatments or injections, sometimes the outcomes are hard to determine.
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