Will Education Stop Physicians from 'Gaming' the Medicare System?

Waste in national healthcare spending can be reduced if physicians received more education about “program integrity,” argue officials from the Centers for Medicare and Medicaid Services (CMS) and U.S. Department of Health and Human Services (HHS).

In the latest issue of the Journal of the American Medical Association, a CMS official and others opine about the need to provide proper training and education ”to ensure that all physicians have sufficient awareness to safeguard public and private healthcare programs, patients, and themselves.” The authors, Shantanu Agrawal of the Center for Public Integrity, CMS,  Julie Taitsman, Office of Inspector General, HHS, and Christine Cassel, American Board of Internal Medicine, argue that ”despite the enormous resources at stake, physicians receive little education in how to manage and steward finite resources, making formal education of physicians in ‘program integrity’ an essential component of medical professionalism.”

“Program integrity,” the authors explain, is “a term frequently used by payers for program losses due to inefficiencies, inappropriate payments, or exploitation–spans the spectrum of waste, abuse, and fraud, which divert healthcare dollars from the provision of patient care.”

Physicians are uninformed about “program integrity” as it relates to Medicare and insurers, the authors write, and as a result contribute to billions of dollars in waste. Physicians violate program integrity by:

• Committing fraud, although the authors acknowledge this is a small percentage;
• Manipulating Medicare reimbursement codes so that patients receive the care  physicians perceive is needed, presumably because Medicare or private payers will not reimburse for the treatment that is required;
• “Gaming” the Medicare and private payer system, by upcoding and other means.

While these reasons appear to contradict the authors’ premise, indicating that physicians who violate revenue integrity know exactly what they are doing, the authors maintain that a formal education program should be “an essential component of medical professionalism.”