TAC probe into improper billing

[injuryupdate]

From:
http://www.theage.com.au/news/nation...234958428.html

TAC probe into doctors' billing
Richard Baker and Nick McKenzie, Age Investigative Unit
May 1, 2008

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THE Transport Accident Commission is auditing the invoices of doctors in Melbourne's biggest public hospitals because of growing concern that improper billing is rife.

The Age believes the TAC is auditing billing records of numerous doctors at The Alfred, Royal Melbourne and Royal Children's hospitals.

The audit is one of several TAC investigations targeting the hospitals and the people providing medical services.

Senior TAC and metropolitan health network sources have told The Age improper billing by doctors was emerging as a systemic problem.

"It appears to be a cultural issue affecting the whole health system," one said this week.

Asked about the investigation, a TAC spokesman said the commission did not have any comment other than to say "they are continuing".

A separate investigation by Victorian Ombudsman George Brouwer is believed to be focusing on the complex financial links between the TAC, senior doctors and public hospitals. Several doctors have been interviewed.

The Medical Practitioners Board of Victoria meets today to discuss the registration of The Alfred's former trauma director Thomas Kossmann, who resigned this month after a peer review report found him to be incompetent in aspects of surgery, and for billing the TAC for operations that were never done.

Bayside Health has advised the board it considers Professor Kossmann, who is accredited to operate at the Epworth hospital, to pose a risk to patient safety.

Professor Kossmann has strongly rejected the findings. But he maintains that if he has a problem with TAC billing, then so do numerous other doctors.

The Age can also reveal new details about the once-close relationship between Professor Kossmann and the TAC. The commission gave him $1.5 million in 2003 to establish the National Trauma Research Institute at The Alfred. Documents show The Alfred is the administering institution for the grant.

The grant was given by a TAC subsidiary, the Victorian Trauma Foundation. At the time it was made, Professor Kossmann was a member of its board. He stepped down from the foundation's board in 2004.

Details of the grant have sparked new conflict-of-interest allegations.

The foundation gave Professor Kossmann's institute $846,000 in 2006-07 for personnel and administration costs.

In addition, the trauma institute has received millions of dollars in research grants from the TAC-backed foundation and other private and public sources.

A TAC spokesman said the foundation's board had proper provisions to ensure there was no conflict of interest.

A spokesman for Professor Kossmann said he removed himself from all boardroom decisions about money for the institute. He resigned as director of the institute this month.

The institute has never been required by Bayside Health to publish an annual report accounting for the expenditure of millions of dollars in public and private donations it has received in the past five years.

This has led to concern among senior medical staff at The Alfred about proper auditing of the institute's finances.

A Bayside Health spokeswoman said grants to the institute were accounted for in detailed financial reporting to the TAC. "The institute is one of many departments of Bayside Health, which is audited annually by the Victorian Auditor-General's Office," she said.

KEY POINTS
■ Senior TAC and health network sources say improper invoicing by doctors is systemic.
■ Audits on records of doctors at The Alfred, Royal Melbourne and Royal Children's.

[injuryupdate]

Perhaps State-Federal cost shifting incentives built into the system may be an underlying reason (apart from human greed) as to why surgeons may be tempted to such abuse.

Please consider from a public hospital's viewpoint:

-Your budget is constantly under massive squeeze with increasing costs and patient loads always seeming to outpace any extra funding you get from either level of government.
-Every public patient who requires surgery is a massive drain on your finances, as you just need to wear the expenses with no respite.
-Every non-public patient (private using no gaps scheme, worker's compensation or transport accident) is a massive bonus for your finances, as accounts can be sent to the external party(s) responsible for paying the bills. In addition to this, you can expect that the patient will be followed up in the surgeon's private rooms so your outpatient service also gets relief. These cases are potentially heavenly for propping up the hospital budget.

Now consider from the surgeon's point of view:

-You earn lucrative amounts of money whenever you operate in the private system, but the work keeps you very busy.
-You get paid a salary for your public work, but it is very modest in comparison to the amounts you can earn from your private operating lists.
-If you are getting overworked and need to cut back somewhere, it is relatively easy to do this for some or all of your public lists, as the lists will go ahead anyway with the (training) registrars performing the surgery. If you are not actually at a given case or even the entire list, you can rationalise that these are 'public' patients and they have to be satisfied with being operated on by whoever they get, be it the consultant (you) or the registrar (the yet-to-be-qualified junior).

Now consider what happens if a potential private (non-public) patient turns out to be on a list at a public hospital and the registrar (not the consultant) has done the surgery. It should be illegal for the patient to be considered a 'private' patient of the consultant, as the consultant wasn't actually there. But if the consultant plays by the rules and does not take this patient on as a private:

-The hospital loses as they can't submit any bills to an outside party.
-The patient sort of loses, as they need to queue up with the cattle for their follow-up at outpatients rather than at the consulting surgeon's rooms.
-The surgeon loses the opportunity to (illegally) bill the patient for an operation he/she didn't do.

It doesn't take much imagination to think that a surgeon in this position, if bereft of ethics (and perhaps looking around to apparently see other surgeons in the same position taking advantage of the situation, if you believe Kossman), may succumb to the temptation. Theoretically the patient could blow the whistle that the surgeon wasn't actually there, but at no cost to him or herself, he/she has been given an upgrade to private follow-up. And anyway, if not told, how does he/she know that the surgeon didn't walk into the room and do the surgery after the anaesthetic was administered?

How much does this go on? It is hard to say from the viewpoint of an outsider, but the article in The Age suggests that those on the inside who matter are starting to think it might be rather often.

A fair analogy might be tax dodging. It is wrong and it is probably done rather a lot, but just because it is not uncommon doesn't stop it from being wrong. Anyone who gets caught should be punished.

If it is true that Thomas Kossmann, as alleged, was billing for surgery that he didn't attend, then he has been dealt his just desserts. But one of his major defences he gave was to the effect of "all I am doing is billing in the same way that I have seen my colleagues billing". Will other surgeons suffer the same fate?

[injuryupdate]

More surgeons face scrutiny over rorts
Richard Baker, Age Investigative Unit

28 July 2008
The Age
[http://www.theage.com.au]

EXCLUSIVE

SEVERAL top Victorian surgeons have been identified in a Transport Accident Commission audit as having submitted $7 million worth of suspect bills, including invoices for "phantom" surgery that never occurred.

Amid concern about surgical rorts due to the controversy surrounding The Alfred hospital's former trauma chief, Thomas Kossmann, the TAC has confirmed it has strengthened billing requirements for surgery performed in Victorian public hospitals and has warned surgeons not to submit multiple invoices for services meant to be covered by one payment.

The Age believes more than a dozen surgeons have been identified for submitting suspect bills in a draft report of a TAC audit undertaken by KPMG.

In addition to bills for surgery that may never have occurred, some surgeons are believed to have billed the TAC for post-operative consultations that should be covered by the initial operation fee.

It is believed the audit found Professor Kossmann to be the surgeon with the most questionable invoices dated between 2001 and 2007. Victoria Police fraud detectives are investigating allegations that he defrauded the TAC.

Professor Kossmann quit as director of The Alfred's trauma centre in April and was later found by a hospital-commissioned inquiry to have engaged in harmful and unnecessary surgery. He was also found to have billed for operations that never happened or were done by other doctors.

The Age has been unable to establish the names of the other surgeons named in the TAC audit, which is examining billing records of surgeons working at major hospitals such as The Alfred, Royal Melbourne and Royal Children's hospitals.

A TAC spokeswoman yesterday confirmed a draft report had been received from the commission's internal auditors. But she would not comment on the monetary value of suspect billing or identify any surgeons named.

"As it is only in draft form, we are not able to discuss the preliminary findings at this stage. We have already moved to strengthen our billing requirements for surgical services in public hospitals," she said.

Several sources have told The Age that the draft report found $7 million in questionable invoices, with the strong possibility this figure will rise as the audit continues.

The draft report's findings increase the likelihood that The Alfred received substantial TAC funds it was not entitled to, through a controversial income-sharing arrangement in which it received half of every TAC fee earned by Professor Kossmann.

Professor Kossmann told The Age in May that The Alfred was well aware of his dealings with the TAC and had received more than $3.6 million through his TAC billing. The Alfred is pursuing the surgeon over $700,000 it claims it is owed through the TAC fee-splitting arrangement.

The TAC audit's findings support Professor Kossmann's claim that other surgeons would have problems with their billing if he was found to have invoiced inappropriately. He has repeatedly said he learned how to bill the TAC by watching his colleagues.

A spokeswoman for Professor Kossmann said the surgeon was not aware of any preliminary findings in the TAC audit. But she said the leaking of the draft report's findings was consistent with the "witch-hunt conducted against Professor Kossmann over the past year".

She said he had nothing to hide over his billing methods and had co-operated with all investigations into his conduct.

Investigators from the State Ombudsman's office are investigating the complex financial relationship between Professor Kossmann, The Alfred and the TAC.

This includes using millions of dollars in TAC funding to establish the National Trauma Research Institute, which was opened in 2004 by former premier Steve Bracks and headed by Professor Kossmann until his resignation.

The TAC pays for the medical treatment of Victorian road crash victims and is funded through a compulsory third-party insurance scheme attached to annual motor vehicle registrations.

[injuryupdate]

Today's article from The Australian probably won't appear online but it is important reading for those following the Kossmann saga at The Alfred.

As is healthy in the media, it seems that The Age have been running most of the anti-Kossmann stories and the News Ltd press has been more defensive.

From my outside reading, I think this is a genuine case that needs both sides seriously looked at, as it appears there are element of both fair and unfair allegations against Kossmann. Although this is probably an oversimplistic summary of the situation, you can divide the allegations down the middle along the following lines:

(1) Improper billing. It has been stated many times in articles that the report into Kossmann found that he billed for procedures where he wasn't performing the operation, and/or added inappropriate item numbers that shouldn't have been claimed. This is a very serious and clearcut allegation. It should be black and white. You are either in the theatre doing what was billed for or you are somewhere else having a registrar do it for you. Kossmann's only defence (including in sympathetic article in The Australian today) is that he was only billing in the same way that his peers were and he basically copied their billing methods. This isn't a reasonable excuse. Billing for surgery you haven't performed is fraud and it is not an excuse to say that 'everyone else is rorting the system so why can't I?' However, just as Kossmann has not seemed to have mounted a proper defence to this allegation, the Alfred or College of Surgeons hasn't defended the counter-allegation that improper billing is commonplace in public hospitals in Australia.

(2) Inappropriate clinical practice. On this side of the argument, it is perhaps true that the allegations resemble a witch hunt. As the article in The Australian stated there are no dead bodies or outraged patients a la Butcher of Bega or Dr Death sagas, yet Kossmann has had a public dissection of his clinical ability to rival these infamous cases. From the readings it sounds like he is a cowboy with respect to the hopeless near death cases, sometimes performing wildly optimistic surgery on a patient who is virtually gone. Some doctors, patients and relatives may find this macabre and others may think he is a hero for trying to work a miracle. In terms of outcome if a patient dies who was going to die anyway, there is little net human cost. It may be that Kossmann can toss in a bill for hugely complex surgery that was expensive but futile, but this argument belongs in the financial column rather than the clinical outcomes column. Certainly the argument made in The Australian that Kossmann may have been victimised because he is a specialist trauma surgeon and this isn't considered a subspecialty in Australia seems to have validity.

[injuryupdate]

Where to from here? If the investigating bodies can prove gross fraud (i.e. multiple instances of billing for procedures not actually performed) then Kossmann deserves to pay a big price. A minimum would be a re-payment of all bills falsely claimed plus a substantial fine, which virtually no one could argue against. The more difficult questions are whether billing fraud, if gross and proven beyond reasonable doubt, should lead to medical de-registration and even possibly criminal sanctions (such as jail). There needs to be a practical consideration in all of this. If Kossmann's counter-allegations are true that there is widespread improper billing occurring in Australia, then it needs to be fully investigated. However, with major shortages in surgeons around the country, we probably can't afford to throw a substantial percentage of our surgical workforce in the clink.

Perhaps a pragmatic solution could be the following:

(1) Draw a line in the sand and clearly state that any future proven cases of surgeons billing for procedures that they didn't actually do will be considered grounds for medical de-registration and criminal charges.
(2) Announce an amnesty that surgeons who have practised in this way in the recent past can declare the practice and avoid deregistration and criminal sanctions. However, they would be required to pay back all money falsely claimed plus a fine.
(3) Surgeons who do not take advantage of the amnesty but who have fradulent billings in their past would risk deregistration and criminal sanctions if these cases were uncovered.

[injuryupdate]

For those who like a good spray, read some of this:

http://www.ombudsman.vic.gov.au/reso...lth_Report.pdf

Billing for surgeries that didn't get done, where he wasn't there, on patients who were about to die etc. plus improper deals with medical suppliers, all to apparently maximise his multi-million dollar income! Wow!

[billing services]

Don't worry about the billing problem,consult us we will guarantee that you claim your billing with satisfaction.

[cortDyncKeync]

this government are cr4p, they promised and then pulled out, teh same is happening or happned to Jaguar/Land Rover, yet they have now managed to secure private funding, they should tell the govenment to go and shove there non existant assistance right up there fiddling bums