I looking at the fraud aspect I found a lot of discussion on short payments, slow payments, costs of management, and frustration. I saw no direct references, but what I did see reminded me of situations I have seen in other industries and the solutions may be similar. To offset the short falls in cost some of the "fraud" may be the attempt to recover costs rather than getting something for nothing.
http://www.aha.org/content/00-10/09medi ... ayment.pdfIn the aggregate, both Medicare and Medicaid payments fall below costs and the shortfall has
been growing.
Combined underpayments rose from $3.8 billion in 2000 to $32 billion in 2008.
For Medicare, hospitals received payment of only 91 cents for every dollar spent by
hospitals caring for Medicare patients in 2008.
For Medicaid, hospitals received payment of only 89 cents for every dollar spent by
hospitals caring for Medicaid patients in 2008.
In 2008, 53 percent of hospitals received Medicare payments less than cost, while 56
percent of hospitals received Medicaid payments less than cost.I was reminded of the situation I saw in car dealerships back in the stone age (collage age for me) where the waranty allowances were insufficient and the mechanics would refuse to do the work. The managers would "pad" the claims with additional work to offset the loss to the mechanic who was paid for the work performed or a small guarantee if there was not sufficient work. This was fraud, but it was a simple work around to get a more fair wage for the mechanic and get the waranty work completed for the customer.
From some of what I have read concerning litigation and attempts to get changes made, I can see where the same type of work around would have an appeal to some operations. I can also see where that could grow into more than a coverage of cost.
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