The Daily

Stark and Quality Fraud

On my blog, I write a lot about #QualityFraud. What this concept means to me is the inflated cost of medicine and other health care costs passed on to consumers through concealment and deception of the quality of the services we are being provided. Unlike any other industrialized country, our health care sector is opaque (not transparent) and as a result the prices we pay are not governed by real market forces. This phenomenon was the subject of David Brill’s excellent treatment for Time Magazine called Bitter Pill: Why Medical Bills Are Killing Us.

CMS (the financial arm of Medicare and Medicaid) is now taking public input on new rules that would change the current “Stark Law” (passed in 1988): rules that prohibit physicians and other healthcare providers from referring patients to clinics or services in which they have a financial interest. According to officials with the agency, CMS is looking for “bold ideas”  to topple the rules against physician self-referral. You can read one of the stories about the proposed rule changes here:  CMS Wants To Dump Conflict of Interest “Burden” for Physicians.

In Florida, we have our own version of the Stark Law. See, Florida Statute Section 456.053.

Florida also has an anti-kickback law to prevent physicians from doing an end run around the conflicts of interest law. Florida Statute Section 456.054

Seema Verma, a CMS official, has been on a “listening tour” of large institutional healthcare providers, physicians and hospitals to find out how badly the medical industry wants to refer patients for tests and screening that they can profit from. My guess is that their answer to all of her questions will be a resounding, “Yes!”.

Here is a Hillsborough County Bar Journal article written on behalf of special interests that would like to gut these laws. FLORIDA’S PATIENT SELF-REFERRAL ACT: THE STARK LAW ON STEROIDS Health Care Law Section Chairs: T.J. Ferrante – Carlton Fields Jorden Burt, P.A.; and Sara Younger – BayCare Health Systems, Inc.

There is no mention, in the articles about CMS and Ms. Verma, of any plan for CMS to “listen” to any ethics organizations, patient advocacy groups or organizations interested in curbing medical costs and fraud.

This is just one more example of an agency buckling to the desires of the businesses they are meant to regulate. In the current Administration, agencies like EPA and HUD have become openly hostile to their own missions in the name of “deregulation” – becoming wholly owned servants doing the bidding of the biggest players in those industries.

So what can we expect if the Stark rules are repealed? Certainly more cases like that of

Sanjoy Banerjee, MD, a pain physician in Corona, Calif., (who) has been charged with workers compensation insurance fraud and perjury by the Riverside County District Attorney.

Here are four things to know:

1. Dr. Banerjee is accused of billing workers compensation for more than $180,000 in urine toxicology testing and epidural injections he illegally self-referred to a laboratory and office-based surgical center he owned. He is the owner of Rochester Imperial Surgical Center in Wildomar, Calif.

2. Previously, Dr. Banerjee signed five doctor’s reports declaring under penalty of perjury that he didn’t self-refer the patients to his lab and surgical center.

3. On May 29, Dr. Banerjee was charged with two counts of insurance fraud and five counts of perjury; he will enter his plea July 7 at his arraignment.

See, Laura Dyrda’s June 8, 2018 article in Beckers.

Presumably, if Ms. Verma and her paymasters get their way, Dr. Banerjee would not be guilty of anything but smart business. Care to guess how many more Dr. Banerjees are likely to pop up across the country should that happen? And what it might end up costing us through CMS funding?

Here is a primer on CMS Fraud and Abuse. In 2015, under the Obama Administration, CMS calculated the cost of fraud and abuse prosecuted under the False Claims Act at $1.9 billion. According to the referenced report updated for 2016, the “Health Care Fraud and Abuse Control (HCFAC) Program has returned more than $29.4 billion to the Medicare Trust Funds.  In this past fiscal year, the HCFAC program has returned $6.10 for each dollar invested.”