Multiple healthcare fraud schemes have been investigated over the years involving providers who misrepresent cosmetic procedures as medically necessary ones to increase patients and their profit. Rhinoplasty is known to be the most common procedure that is inappropriately billed to health insurance. Surgeons charge for repair of a “deviated septum” and then perform cosmetic rhinoplasty. Tummy tucks have also been billed to insurance as hernia repair. Separation of the abdominal muscles is sometimes falsely called a hernia and billed to insurance.
Any effective wasteful spend analysis should routinely conduct review of a focused sample of medical records as an identification and prevention measure. We posted last week about one case.
An example can be seen from a selected visits review ($10,000 – $30,000/per procedure): A 26-year-old female was billed for reduction mammoplasty by a Beverly Hills plastic surgeon. Services that are typically seen prior to this procedure, i.e. physical therapy for back pain or related office visits, were not seen in this member’s medical history prior to surgery.