A hard-hitting, well-documented expose of how physicians milk the
Medicaid system. The cost of Medicaid fraud is unknown, but every
year about two hundred physicians are suspended from the program
because of fraudulent or abusive practices. The authors (all
professors at the School of Social Ecology at the University of
California, Irvine) look at these violations and examine the system
that has provided the opportunity for them as well as the
backgrounds of doctors who commit them. (Some of the violations are
outrageous: bills for therapy while the therapist, a psychiatrist,
was having sex with a patient; bills for abortions on nonpregnant
women.) Medicaid's fee-for-service system makes fraud easy: By
simply checking a box on a form, a doctor (or a billing clerk) can
charge for services not performed. Meanwhile, ripping off the
government apparently doesn't create guilt feelings: Interviews
with 42 physicians reveal that these M.D.s see themselves as the
innocent victims of bad laws and bureaucratic interference. And the
medical fraternity has taken a relatively benign attitude toward
Medicaid fraud, with state regulatory boards rarely revoking
licenses of apprehended physicians. The authors offer no quick
solution to the problem, noting that tension between government
regulation and professional norms of behavior is growing. Finally,
they look at the health-care systems of Great Britain, Canada, and
Australia, to consider how they cope with fraud, concluding that
the problem can be solved only through structural changes in the
delivery of health-care services. Exactly what changes are
necessary remains unclear. More fuel for the debate on health-care
reform, filled with horror stories that can't help but add to the
public's growing disillusionment with doctors. (Kirkus Reviews)
This expose of the US health care system uncovers the dark side of
physician practice. Using interviews with doctors and federal,
state and private officials, it reveals the practices of doctors
who profit from abortions on women who are not pregnant, of
needless surgery, overcharging for services and excessive testing.
The authors trace patterns of abuse to the inauguration of the
American Medicaid programme in the mid 1960s, when government
authorities, not individual patients, were entrusted with
responsibility for payments. Determining fees and regulating
treatment also became the job of government agencies, thus limiting
the doctors' traditional role. Physicians continue to disagree with
Medicare and Medicaid policies that infringe on their autonomy and
judgement. The medical profession has not accepted the gravity or
extent of some members' illegal behaviour, and individual doctors
continue to blame violations on subordinates and patients. In the
meantime, programme guidelines have grown more confusing, blocking
efforts to detect, apprehend and prosecute Medicaid defrauders.
Failure to institute a coherent policy for fraud control in the
medical benefit programme, the authors
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