Sunday, August 16, 2009

Yes, words matter. Even adding one wrong word could cost taxpayers trillions. That is exactly what is being proposed.

Currently, publicly funded programs such as Medicare and Medicaid only pay for medically necessary health care. Sen. Barbara A. Mikulski, Maryland Democrat, publicly said President Obama’s proposed health care plan will pay for “any service deemed medically necessary or medically appropriate.” What a difference the word “or” makes. In other words, no longer would a provider have to show that health care services are medically necessary; they’ll get paid if it is medically appropriate.

Dropping “medically necessary” as a minimum requirement would be disastrous and bankrupt our health care system.

Let me give you an example. If a patient walks in a hospital saying he has a headache or does not feel well, a doctor may order dozens of blood tests and X-rays. This does not meet the medically necessary standard, but could easily fit the definition of medically appropriate.

Think this is fantasy? In December 2000, “HCA The Healthcare Company,” a for-profit hospital chain, paid the government $731.4 million to resolve allegations that, among other things, it billed for lab tests that were not medically necessary. In March 1997, SmithKline Beecham Clinical Laboratories Inc. paid $325 million to settle similar allegations. That is $1 billion from just two companies. With a lower standard being proposed, perhaps these costs would now be paid?

The pharmaceutical companies will not want to miss out on the feeding frenzy. They will push every expensive pill that they think may be medically appropriate. Dentists would want more X-rays because they may be appropriate. Psychologists will want more therapy, as some have already tried billing for group therapy sessions with Alzheimer’s patients. You get the picture. Patients would be seen as cash cows for any test or service a provider can justify as appropriate.

By spending all our limited health care funds on appropriate services, there will not be money left for necessary ones.

We already know that 10 percent of health care bills are fraudulent. Wait until you remove the requirement that all services must be medically necessary. Then the charges we once called fraud would now be allowed. In fact, it would be hard to ever prove another health care fraud case because a provider will clam he thought the costs were “appropriate.”

If you think “cash for clunkers” ran out of money fast, wait until every health care professional starts lining up at the feeding trough to bilk the government out of trillions when you drop the minimum requirement that services be medically necessary.

So, one word “or” could devastate an already struggling economy. Mr. Obama, let’s scrap “or medically appropriate” and leave the “medically necessary” requirement alone.

Joel Hesch is a law professor at Liberty University and leading expert on fraud against the government. He is the author of two books on blowing the whistle on government fraud and worked for more than 15 years in the Civil Fraud Section of the U.S. Department of Justice.

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