‘First, Do No Harm’ – How Financial gains through Fraud can Actually Hurt Patients

From as early as 275 AD, healers have been taking the Hippocratic Oath, in which, among other things they swear to ‘abstain from all intentional wrong-doing and harm’. Probably around the same time frame health care providers began to be paid for their services. I am not sure when the desire for more money (greed) overtook the oath for some, but something tells me it didn’t take too long.

There is a belief among some people that fraud doesn’t really hurt anyone. The insurance companies, the government payers, the pharmaceutical providers have lots of money, so where is the harm? Government payers (Medicare/Medicaid) and commercial payers have Program Integrity (PI) /Special Investigative Unit (SIU) departments respectively. These divisions are created to prevent Fraud, Waste and Abuse (FWA) from occurring and pursuing those who attempt to cheat and steal their way to success.

‘No bad provider provides quality care’. I get some weird looks when I make that statement, but when bad providers put monetary gain above the actual needs of patients, the risk of harm is huge.

Patient safety can be affected in two ways: (1) receiving unnecessary treatments, and (2) not receiving necessary treatments and services. The worst healthcare outcome a patient can face is death or direct harm. Unnecessary treatments can harm patients. The 2022 fraud case of Scott Charmoli, DDS, who intentionally caused damage to teeth so he could bill to repair them, is a grave example and one that we see repeated to lesser extents even today. Not receiving necessary services, can result in patient deaths, such as the case of Mikayla Norman. Mikayla, a 14-year-old with cerebral palsy, weighed only 28 pounds at the time of her death. Providers billed for home and community-based services to care for her but did not provide adequate care. These tragedies are way too common when bad providers are allowed to continue practicing unchecked.

Medicaid and Medicare agencies may be reluctant to fully employ their program integrity capabilities, fearing provider abrasion may create access-to-care concerns. However, this mindset is counterproductive and skirts Medicaid and Medicare responsibilities for health quality/equity and patient safety. This is especially true for patients at higher risk of harm and abuse, like those covered under federal Medicaid waivers designed to allow those patients to remain in the community. Generally, these are patients with a skilled nursing level of care such as senior citizens, medically fragile patients like Mikayla Norman, and patients diagnosed as intellectually and developmentally disabled (IDD). Particularly alarming are allegations around providers who go beyond healthcare fraud, waste, and abuse to include getting IDD patients involved with drug activity and forms of human trafficking.

Clearly, a failure to effectively pursue healthcare program integrity is an admission that these types of patients won’t receive the enhanced program oversight that health quality/equity requires. Not aggressively pursuing FWA may be an invitation for providers that CMS already identifies as high risk for fraud (i.e., home health, transportation, etc.), to commit the types of fraud that put patients at risk of harm and abuse, as well as leading to poorer health outcomes.

The moment healthcare providers chase money through fraud they cannot be focused on quality care. Advanced data analytics, unstructured text analysis and multivariate anomaly detection are ways to spot not only fraudulent activity but quality of care issues. The solution PI/SIU’s choose to do their work should be able to examine the issues from both sides. It is up to us, the fraud fighters, to protect those who cannot protect themselves and protect the funding that is in place to support those most in need. 

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