John O'Connor

Some necessary conversations tend to be awkward and uncomfortable.

They include talking to our children about baby making. Or convincing our parents to give up the car keys. Or talking to government investigators about those astronomical therapy billings.

Wait, what was that last one again?

Sorry, but it’s time to have an adult conversation about a chronic problem that continues to worsen: healthcare fraud.

Now I realize this type of chat tends to make all involved feel uncomfortable and itchy. If it helps, let’s begin with this assumption: Most operators in this field are trying to succeed in a complicated business environment without intentionally breaking the rules.

I think most of us can agree with that premise.

But given how easy it is to cheat these days, we probably shouldn’t be terribly surprised that so many operators give in to temptation. That’s especially the case when it comes to invoice preparations.

Let’s be honest: How hard is it to put a resident in a higher RUGs category than is probably accurate? Or to bill for therapy services that were not actually delivered? Or to have therapists working overtime doing services that never should have occurred in the first place? And that, my friends, is just the tip of the proverbial iceberg.

Throw in stiff competition, incentives that reward upcoding, a dearth of interested investigators and good old-fashioned human greed, and what we have here is a breeding ground for creative accounting.

Should you have any doubt that these conditions are fueling actual larceny, I invite you to Google “healthcare fraud.” Let’s just say you’ll have plenty of reading material.

It’s not like the federal government is unaware of the mischief. Uncle Sam simply doesn’t have enough resources to keep up.

But times are changing. With each passing year, more federal activity is being directed toward finding and prosecuting those who cheat, steal and lie their way to better payments. We’re also starting to see analytics being used to reveal billings that don’t make sense.

The reality is this: Cheating is going to become an increasingly risky option. But given the easy money just sitting there for the taking, there will always be operators who don’t think they will get caught.

There’s a way to describe what they are living on. It’s called borrowed time.