On Friday, The Federalist posted an article illustrating how easy it is for a healthcare provider to commit healthcare fraud. The article tells the story of a woman who went for her annual visit to her allergist and what happened next.

The article reports that when she received her statement of the charges for the visit something wasn’t quite right:

Upon receiving this statement, I immediately questioned the line for “Laboratory Services” in the Explanation of Benefits. At the time, I assumed this line was for a breathing test that my regular provider said I did not need — and which she did not perform on the date of service. However, because this provider (who has since retired) had expressed some discomfort about her working arrangement in the larger allergy practice, I decided not to pursue the matter further at that point, to spare her additional stress.

In recent months, I learned that the practice’s owner had not just sold that practice, but that the entire practice — and he personally — had filed for Chapter 7 bankruptcy. The comments that staff at the succeeding practice made to me about the prior practice being mismanaged and “run into the ground” renewed my interest in pursuing the circumstances behind the Nov. 18, 2022, claim.

A few weeks ago, I spoke with staff at CareFirst about this claim. The staff informed me that, according to the diagnosis codes submitted as part of the claim, the “Laboratory Services” line was not for a breathing test but a Covid test.

As you might suspect, I did not receive a Covid test during this office visit.

The article notes:

Even though I did not meet my annual deductible for 2022, CareFirst still paid for the office visit with no out-of-pocket expense on my part, simply because the allergist’s office claimed they provided a Covid test during the visit. That dynamic provides a perfect recipe for fraud because scammers recognize that far fewer patients would dispute a potentially fraudulent claim if their office visit was provided to them for “free.”

…Trying to report this potential fraud has proven the most infuriating experience of all. As you can see from my Explanation of Benefits, CareFirst advertises a fraud reporting line on all claims. But when I tried to call, I discovered that this line only operates during working hours, despite the fact that the fraud reporting line is an automated system. Worse yet, CareFirst promises a response within one business day, but after several days, it has yet to return my voicemail.

The article concludes:

I work in health policy, yet I feel like I’ve spent the better part of the past week on a wild goose chase trying to figure out how and where to report this suspected incident of fraud. Most normal people who don’t do this for a living would have given up a long time ago.

Therein lies the moral of the story: We need to make it harder to cheat the system and easier to report those who do. Unless and until we do so, no one should sound surprised the next time they hear a story about yet another health fraud scam.

Someone was paid for the Covid test that never happened. Someone paid the co-pay on the office visit because of the Covid test that never happened. Please follow the link to read the entire story. Medical fraud is a serious problem.