Billing Code Battles, And 900 Endoscopies Claimed For One Patient

medical files

Mega-billing. That's the theme that jumps out at me as I trawl today's news. NPR's Marketplace offers a lively segment here on a South Carolina urologist, Larry Rabon, who drafted his family in his effort to bill better — that is, more extensively, though still legitimately — and raised his revenues by 70 percent, hundreds of thousands of dollars. Marketplace's Gregory Warner caught him at the "Coding Con" conference in Orlando, teaching other doctors how to do the same. Harvard health economist David Cutler offers the background:

"He's just charging for every little thing he's doing. It's like a code war between doctors and insurance companies. And the hotter this war gets, the more it costs... us. Our premiums and taxes pay for the coding gurus and soldiers on each side. There are now 2.2 people doing billing for every one doctor in America.

Cutler: It's a major part of the health care industry spent just dealing with that back and forth.

That back and forth — you'd know this if you've ever been caught up in it — means reams of extra paperwork and referrals and authorizations and denials and appeals and this costs an extra $360 billion a year. That's according to the Institute of Medicine. Which is to say, if we could just shave off one seventh of the extra bureaucracy...

Cutler: That's well more than it would cost to bring insurance coverage to every single American who is now uninsured.

And as if that weren't dark enough, here's the really dark side of billing: NPR's Scott Hensley tweeted a link to this New Jersey report on Dr. Michael P. Stein, who was just sentenced to 24 months in prison for fraudulent billing. I mean, really fraudulent. Like, claiming he performed a nasal endoscopy — a common diagnostic tool — 900 times on one patient. From the release:

Between August 2004 and September 2010 Stein was the owner and operator of Randolph Otolaryngology P.C., a medical treatment facility. Stein treated a patient with the initials J.F. for nasal problems and billed Blue Cross Blue Shield for the services he purportedly performed.

Stein admitted he filed fraudulent claims with Blue Cross Blue Shield for medical procedures that were not performed during office visits. Stein submitted claims for approximately 900 nasal endoscopies he purportedly conducted on the patient, when only a few were actually performed.

This program aired on April 11, 2012. The audio for this program is not available.

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Carey Goldberg Editor, CommonHealth
Carey Goldberg is the editor of WBUR's CommonHealth section.



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