Let’s stand up for what is right! - page 4

Why is it okay for a few Republicans Senators with NO MEDICAL EXPERIENCE “write” a new bill for health-care? Honestly, this is not right. We the people elect Congress, which is the House of... Read More

  1. by   Lil Nel
    Yes, you are right, Nursej. Republicans do want the majority of Americans to believe that healthy adults are gaming the Medicaid system. That narrative plays very well to their rabid base that keeps them in power.
  2. by   SC_RNDude
    No, it's not fraud or gaming the system it is the big issue in my view. It's that Medicaid has resulted in over-consumption if health services.

    When things are free, people use more then what they need.
  3. by   toomuchbaloney
    Quote from SC_RNDude
    No, it's not fraud or gaming the system it is the big issue in my view. It's that Medicaid has resulted in over-consumption if health services.

    When things are free, people use more then what they need.
    Can you please give me some examples of this?
    I absolutely am interested in reducing fraud in Medicaid, as are most fiscal conservatives. I simply think that over emphasis on patient fraud with little public concern for provider fraud is disingenuous in our political conversation.
  4. by   herring_RN
    These were settled just yesterday. It goes on all the time.
    June 26, 2017; U.S. Department of Justice
    Cardiac Monitoring Companies and Executive Agree to Pay $13.45 Million to Resolve False Claims Act Allegations
    AMI Monitoring Inc. aka Spectocor, its owner, Joseph Bogdan, Medi-Lynx Cardiac Monitoring LLC, and Medicalgorithmics SA, the current majority owner of Medi-Lynx Cardiac Monitoring LLC, have agreed to resolve allegations that they violated the False Claims Act by billing Medicare for higher and more expensive levels of cardiac monitoring services than requested by the ordering physicians, the Department of Justice announced today. Spectocor and Bogdan have agreed to pay $10.56 million, and Medi-Lynx and Medicalgorithmics have agreed to pay $2.89 million.

    June 26, 2017; U.S. Department of Justice Medicare Fraud Strike Force Case
    Orlando Doctor and Infusion Clinic Owner Sentenced to 64 Months and 90 Months in Prison for Role in Medicare Fraud
    An Orlando medical doctor and an infusion clinic owner were sentenced to 64 months in prison and two years supervised release, and 90 months and two years supervised release, respectively, today for their roles in a $13.7 million Medicare fraud conspiracy that involved submitting claims for expensive infusion-therapy drugs that were never purchased, never provided and not medically necessary.

    June 26, 2017; U.S. Attorney; Eastern District of Tennessee
    Former Clinical Pharmacy Manager Sentenced to Serve 16 Months in Prison for $4.4 Million TennCare Fraud Scheme
    GREENEVILLE, Tenn. - On June 26, 2017, Amber Reilly, 33, of Jonesborough, Tennessee, was sentenced by the Honorable J. Ronnie Greer, U.S. District Judge, to serve 16 months in federal prison for healthcare fraud, which resulted in at least a $4.4 million loss to TennCare. Upon her release from prison, she will be supervised by U.S. Probation for three years.

    June 26, 2017; U.S. Attorney; Western District of Oklahoma
    Norman Orthopedic Practice Pays $1,537,796 to Resolve Allegations of False Claims Submitted to Federal and State Programs for Medical Services
    Oklahoma City, Oklahoma - Orthopedic AND Sports Medicine Center-Norman, P.C., and its physician-owners, Dr. Mark Moses, Dr. David Bobb, Dr. William Harris, Dr. Vytautus Ringus, Dr. Steven Schultz, and Dr. Brad Vogel (collectively "OSC") have paid $1,537,796 to settle civil claims stemming from allegations that they submitted false claims to Medicare, Medicaid, the Department of Veterans Affairs, and TRICARE.
    Criminal and Civil Enforcement | Fraud | Office of Inspector General | U.S. Department of Health and Human Services
  5. by   SC_RNDude
    Quote from toomuchbaloney
    Can you please give me some examples of this?
    I absolutely am interested in reducing fraud in Medicaid, as are most fiscal conservatives. I simply think that over emphasis on patient fraud with little public concern for provider fraud is disingenuous in our political conversation.
    Hang out in a busy ER for any length of time, and you'll see examples of over-consumption and misuse of services all day/night long. People who don't pay anything, but decide something needs to be "checked out", and the ER is free and convenient.

    Busy peds ER's are the worst.

    Some of my fav chief complaints:

    -stomach ache x 1 hour (triage nurse: "could you have your child come on over from running and jumping around on the furniture so I can look at him. And please put away the Taco Bell until you are seen by the provider").

    -Dx with strep today. Still has sore throat and fever.

    -cough and stuffy nose (in my experience, most common CC in peds ER)

    -vomited in car about 15 minutes ago, after lunch. We were driving by so thought we would come in.

    The peds ER I once worked at saw about 250 kids a day. About 55% were medicaid or some form of public coverage. I don't have a number, but a healthy % of those should have gone to PCP's, if anywhere at all.

    I'm sympathetic to some parents whose kids were sent home from school, can't go back until they are seen, parents can't work until kid back in school, and the ER is the only place they can get in. I also realize some, especially new parents, are just nervous and need education (such as to to the wonders of tylenol and PO fluids, with maybe some bulb suction,for example).

    However, many, many just want their minor conditions fixed now, the ER is always open, and it's "free".

    Charge a $10 co-pay, and medicaid would be far less costly to the taxpayer.
    Last edit by SC_RNDude on Jun 27 : Reason: edit
  6. by   Avid reader
    Quote from SC_RNDude
    Hang out in a busy ER for any length of time, and you'll see examples of over-consumption and misuse of services all day/night long. People who don't pay anything, but decide something needs to be "checked out", and the ER is free and convenient.

    Busy peds ER's are the worst.

    Some of my fav chief complaints:

    -stomach ache x 1 hour (triage nurse: "could you have your child come on over from running and jumping around on the furniture so I can look at him. And please put away the Taco Bell until you are seen by the provider").

    -Dx with strep today. Still has sore throat and fever.

    -cough and stuffy nose (in my experience, most common CC in peds ER)

    -vomited in car about 15 minutes ago, after lunch. We were driving by so thought we would come in.

    The peds ER I once worked at saw about 250 kids a day. About 55% were medicaid or some form of public coverage. I don't have a number, but a healthy % of those should have gone to PCP's, if anywhere at all.

    I'm sympathetic to some parents whose kids were sent home from school, can't go back until they are seen, parents can't work until kid back in school, and the ER is the only place they can get in. I also realize some, especially new parents, are just nervous and need education (such as to to the wonders of tylenol and PO fluids, with maybe some bulb suction,for example).

    However, many, many just want their minor conditions fixed now, the ER is always open, and it's "free".

    Charge a $10 co-pay, and medicaid would be far less costly to the taxpayer.
    Trump attorney Jay Sekulow’s family has been paid millions from charities they control - The Washington Post

    This is what fraud looks like!!
  7. by   Lil Nel
    Quote from SC_RNDude
    Hang out in a busy ER for any length of time, and you'll see examples of over-consumption and misuse of services all day/night long. People who don't pay anything, but decide something needs to be "checked out", and the ER is free and convenient.

    Busy peds ER's are the worst.

    Some of my fav chief complaints:

    -stomach ache x 1 hour (triage nurse: "could you have your child come on over from running and jumping around on the furniture so I can look at him. And please put away the Taco Bell until you are seen by the provider").

    -Dx with strep today. Still has sore throat and fever.

    -cough and stuffy nose (in my experience, most common CC in peds ER)

    -vomited in car about 15 minutes ago, after lunch. We were driving by so thought we would come in.

    The peds ER I once worked at saw about 250 kids a day. About 55% were medicaid or some form of public coverage. I don't have a number, but a healthy % of those should have gone to PCP's, if anywhere at all.

    I'm sympathetic to some parents whose kids were sent home from school, can't go back until they are seen, parents can't work until kid back in school, and the ER is the only place they can get in. I also realize some, especially new parents, are just nervous and need education (such as to to the wonders of tylenol and PO fluids, with maybe some bulb suction,for example).

    However, many, many just want their minor conditions fixed now, the ER is always open, and it's "free".

    Charge a $10 co-pay, and medicaid would be far less costly to the taxpayer.
    These are not examples of fraud. These are examples of poor choices, probably the result of lack of education.

    Fraud is a deliberate act committed by a person(s) who knowingly commit an illegality for profit, such as the examples provided by Herring.

    The other day, I took care of a heart cath patient and checked his glucose level. It was well over 300. We had a discussion of the importance of self-checking these levels at home. The patient understood the dangers of not checking glucose levels, but admitted he doesn't do it at home because he doesn't like the "finger stick."

    This is a patient who will probably end up in the ER for either sky-high or dangerously low glucose levels. Largely preventable.

    The Medicaid rolls probably could be culled if we could somehow go back in time and reverse bad parenting, poor choices and lack of education. I would support that notion.

    But I can't support the current Republican plan, and neither does most of the nation. The Republicans had eight years to come up with an alternative. Instead, they choice to flap their gums and win easy votes. But their latest failure is now going to cost them votes in the 2018 midterm elections.

    This latest development is a major setback for McConnell. His ducklings aren't obeying his commands.
  8. by   nursej22
    I have heard and read stories about people "abusing" the ED way before the Affordable Care act; EMTALA used to be blamed. I can remember parents bringing in kids, insisting they be admitted, and then disappearing for the weekend, essentially using the hospital for a free baby sitter. And as far as "they should go to their PCP", good luck getting in.

    When my kids were little, I was told more than once when they needed to be seen that there were no openings and to take them to ED. My youngest son, was on Medicaid until 2 months ago, because he was working 2 part jobs that didn't offer insurance. In the 2 years that he was on it, he went to his PCP twice. Once for his asthma, where he was prescribed an inhaler with a $300 co-pay, and another time for sore throat and cough and fever. He was sent to ED for possible sepsis, even though he didn't want to go. He got several eye rolls, a CXR, and half a liter of IVF, even though I heard the doc say he should finish it. The ED nurse decided he didn't (it was the end of her shift). Or maybe she assumed he was defrauding the system.
  9. by   toomuchbaloney
    As has been pointed out, abuse or misuse is not the same as fraud.

    I my view, patient fraud is more like obtaining an opioid prescription so that you can sell the drugs.
  10. by   SC_RNDude
    Quote from Lil Nel
    These are not examples of fraud. These are examples of poor choices, probably the result of lack of education.

    Fraud is a deliberate act committed by a person(s) who knowingly commit an illegality for profit, such as the examples provided by Herring
    Perhaps you and others weren't paying attention.

    Prior to my post, I said this:

    "No, it's not fraud or gaming the system it is the big issue in my view. It's that Medicaid has resulted in over-consumption of health services.

    When things are free, people use more then what they need."

    And, then TooMuchBaloney asked for examples. For which I provided. After first saying, "Hang out in a busy ER for any length of time, and you'll see examples of over-consumption and misuse of services all day/night long."

    I didn't say any of this was fraud.
  11. by   Lil Nel
    Fair enough, Dude.

    But your examples of overuse/misuse still aren't reason enough in my opinion to enact McConnellcare.

    Again, I wish we could go back in time and undo poor parenting, poor choices, etc. But we can't. So why harm a whole lot of people, for the foolish mistakes of some? As my example demonstrated, you just can't change the behavior of some patients. All you can do, is meet them where they are. That has been a hard lesson for me to learn as a nurse. And that's because I want patients to change their behavior for the better!

    Fortunately, Americans are slowing waking up to just what this plan entails. And that is why approval ratings for the plan are so low, and why Republicans can expect an earful when they return home during the Fourth of July break.

    I don't disagree that Obamacare needs tweaking. But this plan is a disaster. After eight years of complaining and whinning, this is what Republicans come up with?
  12. by   toomuchbaloney
    So while fully insured people visit with health providers seeking antibiotics for every sniffle and expensive diagnostics for every ache and pain clogging provider schedules with unnecessary visits, we fret about the same behavior from poor people whose access is often limited to the ED.

    How annoying for ED staff. At the same time that this is a symptom of a failing profit based health system it is also a symptom of generalized ignorance in the population.

    Nothing in the Republican health bill will decrease the behaviors you describe. It will simply guarantee that a higher percentage of the visits will be unpaid resulting in more job losses and closure of facilities that serve poor communities, IMO.
  13. by   MunoRN
    Quote from SC_RNDude
    Hang out in a busy ER for any length of time, and you'll see examples of over-consumption and misuse of services all day/night long. People who don't pay anything, but decide something needs to be "checked out", and the ER is free and convenient.

    Busy peds ER's are the worst.

    Some of my fav chief complaints:

    -stomach ache x 1 hour (triage nurse: "could you have your child come on over from running and jumping around on the furniture so I can look at him. And please put away the Taco Bell until you are seen by the provider").

    -Dx with strep today. Still has sore throat and fever.

    -cough and stuffy nose (in my experience, most common CC in peds ER)

    -vomited in car about 15 minutes ago, after lunch. We were driving by so thought we would come in.

    The peds ER I once worked at saw about 250 kids a day. About 55% were medicaid or some form of public coverage. I don't have a number, but a healthy % of those should have gone to PCP's, if anywhere at all.

    I'm sympathetic to some parents whose kids were sent home from school, can't go back until they are seen, parents can't work until kid back in school, and the ER is the only place they can get in. I also realize some, especially new parents, are just nervous and need education (such as to to the wonders of tylenol and PO fluids, with maybe some bulb suction,for example).

    However, many, many just want their minor conditions fixed now, the ER is always open, and it's "free".

    Charge a $10 co-pay, and medicaid would be far less costly to the taxpayer.
    Medicaid does have copays, typically ranging from $3 to $10 for an ER visit, it varies by state and by income.

    One thing that appears pretty well established is that Medicaid patients underuse primary and ER services, this is part of our cost problem is that too often we're treating these patients in an advanced, severely acute phase of a disease process that could have been much cheaper to treat if caught earlier.

    As for ER use, I see plenty of people who didn't need to come in, but there also far more people who come in much later than they should have, and it's those folks who cost our system massive amounts, not the people coming in for the sniffles.

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