Is Your Doctor Committing Fraud?
Suppose you go to your doctor, who recommends you see a specialist. The specialist recommends surgery that is fairly routine, but is still invasive and costly to you or your insurance. If you are in pain or distress, or are simply worried, you may not want to wait long enough to get that second opinion, even though your health insurance or Medicare will pay for it. After all, the doctor in front of you says you need the surgery, and we tend to trust people in white coats.
Most of us don’t question the doctor, especially if it is our heart or other vital organ, or if our mobility is hindered. Practically none of us have the expertise to ask the right questions about the necessity of the surgery, or what alternatives to surgery might be just as good. If death is mentioned, we just want to sign whatever we need to sign in order to have our lives saved.
While virtually all doctors are ethical, caring human beings, if a doctor feels the strong lure of easy money, especially if he or she has financial stresses, they can slide into unethical behavior and decide to commit fraud. Medicare and Medicaid money is often seen as “easy to get” by the unethical. And that is exactly what a number of doctors have been doing—pushing unnecessary surgery in order to generate billings paid for by Medicare and Medicaid.
Surgeries Commonly Involved in “Unnecessary Surgery” Fraud
Common surgeries can be unnecessary, whether due to fraud, misdiagnosis, lack of knowledge concerning alternative treatments, or even fear of being sued for not recommending surgery. The list below names some of the most frequently performed surgical procedures:
- Cardiac procedures, such as stents, pacemakers, or catheterization
- Back surgery or spinal fusion
- Knee or other joint replacement
- C-Section (Caesarean section birth).
Of course, most of these surgeries are done because of real medical need. However, because they are so routine, there is always the chance that the unscrupulous will be tempted to cash in by recommending such procedures when they are not needed.
Risks of Unnecessary Surgeries
All surgeries carry some risk, but unneeded surgeries carry all the risk because there was no reason in the first place for the patient to undergo the surgical hazards. These risks go beyond financial losses. For example, anesthesia has dangers up to and including death, especially for folks over 65. There are also strong risks of anesthesia-induced dementia for the over-65 group, rendering the patient incapable of taking care of himself after surgery.
Additional risks include:
- Complications such as infection, paralysis, or stroke, especially after stents. One to two percent of stent surgery patients experience such complications.
- Post-operative infections in all surgical patients.
- Pain, along with decreased future mobility and capacity, in many surgical patients.
- Permanent diminished cardiovascular capacity, which can happen after installing an unnecessary pacemaker.
- Financial burdens of medical procedures that were not needed.
Recent Cases of Unnecessary Surgical Fraud
It’s been charged that tens of thousands of unnecessary surgeries happen each year. Sometimes these cases end up as malpractice legal actions, but the speculation is that the actions amount to only a fraction of the legitimate unneeded surgeries that occur. Dr. Lucian Leape, a professor at the Harvard School of Public Health who is a former surgeon, commented, “It’s a very serious issue, (and) there really hasn’t been a movement to address it.”
In northwest Indiana, dozens of people have joined a lawsuit against three cardiologists for performing unnecessary procedures since 2014. Some close to the case have speculated that as many as 75 percent of the surgeries done were unnecessary. One patient who sought second opinions after the fact found out that as many as 10 angiograms, one defibrillator installation, and various pacemaker surgeries performed on him were never needed.
In California during September, 2015, it was reported that unnecessary surgeries done by untrained associates resulted in a $150 million insurance scheme, one of the state’s biggest such scams. Many patients required additional surgeries to repair the damage done.
Some of the unneeded-surgery cases that closed in 2015 include:
- An Ohio cardiologist who was convicted of performing unnecessary coronary bypass surgeries, catheterizations, stents, and tests.
- A Florida physician who paid $4 million to resolve claims that he performed surgeries which were either medically unnecessary or not performed at all.
- Also in Florida, $1.2 million was paid to resolve a case involving medically unnecessary angioplasties and thrombectomies.
Some experts have speculated that as many as 20 percent of surgeries in some medical specialties are unnecessary. Over the past decade, over 1,000 doctors have either closed or paid to settle surgical malpractice claims because of charges of inappropriate or unneeded procedures. Unnecessary surgeries or procedures, meaning those without a legitimate medical need, can constitute medical malpractice.
When life goes wrong, we fight for what’s right.
Medical malpractice in South Carolina is a politically charged issue, which has led to an extremely complex set of laws in our state governing malpractice lawsuits. If you or someone you care about has been injured by the negligence of a medical professional, and you suspect the surgery or procedure that was done was unnecessary, you should speak with an experienced medical malpractice attorney like the ones at the Louthian Law Firm as soon as possible.