Why do we have so much fraud in our health care system? Because the system’s incentives encourage it — and because authorities often don’t do enough to fight it.
One of my recent experiences with the system reinforced those two simple and unsurprising lessons. I feel obligated to share the story of how I stumbled upon a possible Covid testing scam (with names and details omitted for legal purposes), to demonstrate how easy it remains for scammers to manipulate our health care system in ways that raise costs for all of us.
Nonexistent Testing
In the fall of 2022, I went for an annual allergy check-up. Shortly thereafter, I received the following statement from CareFirst Blue Cross, my insurer:
Upon receiving this statement, I immediately questioned the line for “Laboratory Services” in the Explanation of Benefits. At the time, I assumed this line was for a breathing test that my regular provider said I did not need — and which she did not perform on the date of service. However, because this provider (who has since retired) had expressed some discomfort about her working arrangement in the larger allergy practice, I decided not to pursue the matter further at that point, to spare her additional stress.
In recent months, I learned that the practice’s owner had not just sold that practice, but that the entire practice — and he personally — had filed for Chapter 7 bankruptcy. The comments that staff at the succeeding practice made to me about the prior practice being mismanaged and “run into the ground” renewed my interest in pursuing the circumstances behind the Nov. 18, 2022, claim.
A few weeks ago, I spoke with staff at CareFirst about this claim. The staff informed me that, according to the diagnosis codes submitted as part of the claim, the “Laboratory Services” line was not for a breathing test but a Covid test.
As you might suspect, I did not receive a Covid test during this office visit. Indeed, I have never received a Covid nasal swab test performed in a physician’s office, as opposed to an antigen test self-administered at home. I did test positive for Covid via an antigen test a few weeks after the appointment in question, but at the time of my visit, I had no symptoms to warrant such a test being performed — and it was not.
It is, of course, possible that the erroneous claim for Covid testing occurred innocently, perhaps because staff confused my claim with another patient’s. However, given the practice’s subsequent bankruptcy and the comments I heard regarding financial mismanagement, it seems more likely that someone viewed submissions for Covid testing that never took place as one way to increase revenues at a firm suffering from financial difficulties.
How Congress Helped Create the Problem
As you might also suspect, lawmakers helped create the conditions that allowed this possible scam to flourish. Specifically, Section 6001 of the Families First Coronavirus Response Act prohibited cost-sharing for any services associated with Covid testing for the duration of the pandemic’s public health emergency.
Even though I did not meet my annual deductible for 2022, CareFirst still paid for the office visit with no out-of-pocket expense on my part, simply because the allergist’s office claimed they provided a Covid test during the visit. That dynamic provides a perfect recipe for fraud because scammers recognize that far fewer patients would dispute a potentially fraudulent claim if their office visit was provided to them for “free.”
I can understand the desire to promote Covid testing during the pandemic’s earliest stages. But providing “free” tests and office visits associated with those tests only encouraged the proliferation of scams. By late 2021, so many at-home antigen tests had been approved that the Biden administration announced it would ship them directly to American households. That development would have provided a perfect opportunity for Congress to scale back the testing mandate. But instead, the requirement to cover office visits associated with Covid tests remained in place until May 2023, when the declared public health emergency finally ended.
Indifference to Scams?
Trying to report this potential fraud has proven the most infuriating experience of all. As you can see from my Explanation of Benefits, CareFirst advertises a fraud reporting line on all claims. But when I tried to call, I discovered that this line only operates during working hours, despite the fact that the fraud reporting line is an automated system. Worse yet, CareFirst promises a response within one business day, but after several days, it has yet to return my voicemail.
District of Columbia authorities have proven similarly disinterested. Neither the Office of the Attorney General nor the Department of Insurance has clearly visible information on their websites about how to report suspected health care fraud. Staff for the attorney general directed me to the Department of Health Care Finance, but that department’s jurisdiction seems confined to Medicaid, and my incident took place in an Exchange plan. Staff for the Department of Insurance haven’t even responded to my calls. Federal officials would logically wish to focus their efforts on abuse of federal taxpayer dollars; while this possible testing scam could have extended to patients in Medicare or other federal programs, I have no evidence of that.
I work in health policy, yet I feel like I’ve spent the better part of the past week on a wild goose chase trying to figure out how and where to report this suspected incident of fraud. Most normal people who don’t do this for a living would have given up a long time ago.
Therein lies the moral of the story: We need to make it harder to cheat the system and easier to report those who do. Unless and until we do so, no one should sound surprised the next time they hear a story about yet another health fraud scam.