As a small, private practice in Boston, we have needed to opt out of most insurances, one of those being Medicare. As our healthcare system has evolved, increasing health insurance restrictions make it harder, not easier, to treat all types of patients. In order to continue providing high-quality care as an ambulatory hernia clinic, we opted to remove the red-tape, and operate out of network.
Yesterday, 3 years after we made that decision, Boston Hernia received our first Medicare audit.
For those unfamiliar, a Medicare audit is essentially Medicare demanding the money back for surgery they already have paid for; because they believe you may have committed fraud with your level of care.
Being direct, a Medicare audit is one of the worst things that can happen to your practice. Your choices are:
Either return the money, or fight it - which requires time, documentation, and effort, all of which pull focus away from patient care.
After reviewing the document, we were shocked when we realized Medicare was challenging only one patient.
The story:
Shortly before I opted out of Medicare, we treated an elderly man with a recurrent inguinal hernia. His first two repairs were performed at a major Boston teaching hospital using a plug and patch… a method we do not use due to its high complication and recurrence rate. The first repair failed almost immediately. The surgeon then used another plug, which also failed.
I accepted him as a new patient, suspecting one thing: his hernia repair was most likely going to be complex.
That proved to be true.
The fast recovery inguinal hernia repair typically takes 45 minutes to complete. Two hours into this case, I had to call in my partner, Dr. Fullington. The previous mesh plugs had migrated and were attached to his intestines. Together, we spent over four hours removing the migrated mesh plugs, preserving the intestine, and repairing the current hernia.
Given the complexity and long operative time, I processed and billed the repair at a slightly higher level. In regards to insurance, a more complex surgery = more $.
Now, years later, Medicare claims the charge was fraudulent, and wants the money back.
So, what?
Well, this patient isn’t an isolated issue. Rather, this story, from failed hernia repairs to a Medicare audit, is representative of our failing healthcare system......
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