It’s broken, but ...

To the editor:

I agree the health care system is broken, but the system is loaded with fraud! No one seems to be targeting the fraud. If not eliminated, these considerable costs go back to the patients, either in direct billing or insurance costs.

Health insurance organizations and health providers have the computers and software for handling medical billing, and today most of this is done electronically with providers originating claims direct to insurance or Medicare and the patients do not see any of this until a claims settlement is issued by the insurer.

In a recent example of this: A family member was in the hospital for about a week where a couple of doctors provided services. The hospital and doctors were provided the proper insurance and patient identification with assignments and were paid in the proper manner.

Later a “CMS Medical Summary Notice” and statement were received using one of the legitimate doctors’ names as the referring doctor to a sleep clinic where a half dozen other doctors whose names could not even be found in the telephone directory generated a fraudulent “claim” for more than $1,000 filed with Medicare, using a proper Social Security number. It so happened that this family member did not have Medicare and thus it was turned down. If she had Medicare, it probably would have been paid before we ever knew what was taking place.

The system administrative procedures need to be altered to keep the patient in the loop requiring his or his custodians to review and approval of all claims before they are paid. This would eliminate much of the fraud.

While no one will admit it, procedures and actions make it clear that everyone accepts the fraud as a part of the cost of doing business. This is the thing that has to change! Focus on the fraud and get rid of it and costs will come down.

FRANK B. TURBERVILLE Jr.
Milton, N.C.