Preventive Medicine and the Seven Deadly Sins: Avoiding Discipline Against your
Medical License
Excerpted from October 2007 Newsletter
by Laura Sweet, Deputy Chief of Enforcement
Medical Board of California
This is the sixth of seven articles in the series, "Preventive Medicine and the
Seven Deadly Sins." This quarter's issue explores the sin of greed.
Greed n. Inordinate or reprehensible acquisitiveness: avarice
"The point is, ladies and gentlemen," Gordon Gekko pontificated in the movie "Wall
Street," "that greed - for lack of a better word - is good. Greed is right. Greed
works. Greed clarifies, cuts through, and captures the essence of the evolutionary
spirit. Greed, in all of its forms - greed for life, for money, for love, knowledge
- has marked the upward surge of mankind."
We are a conflicted society. Reprehensible acquisitiveness versus the upward surge
of mankind. What a dichotomy.
The sad truth is, the sin of greed is so pervasive that it will be a challenge to
find ways to surprise you with its more shameful manifestations. The more classic
incarnations of greed - Medicare fraud, Medi-Cal fraud, insurance fraud, income
tax evasion, mail fraud - they have become so prolific they are mundane to most
investigators. During F/Y 2005-2006, the Medical Board received 294 complaints alleging
fraud. Obviously, the temptation for many to make a quick and easy buck is not surmountable,
but here I must warn you. Should this errant fantasy befall you, I hope you will
consider that physicians who have been convicted of fraud often aren't invited to
attend physician conferences in a district office. They don't come to us. We go
to them. In prison, that is, since often this is the locale where we must
conduct the interview to hear our subject's story about what prompted him or her
to stray. Or how about having a new title to disclose on a job application, something
that looks like ... felon? I would hope that most of these doctors would
no longer agree that "Greed is right."
According to the United States General Accounting Office and health insurance industry
sources, between 3% and 10% of any state's Medicaid budget is lost due to fraud
and abuse. The federal Office of the Inspector General's Medicaid Fraud Control
Unit convicted 1,226 individuals in Fiscal Year 2006 and recovered more than $1.1
billion in court-ordered restitution, fines, civil settlements and penalties. Additionally,
due to health insurance fraud, 3,425 practitioners were excluded from participation
in the Medicare, Medicaid and other federal healthcare programs.
California's Medi-Cal losses reach billions of dollars annually. In Fiscal Year
2005-2006, the Bureau of Medi-Cal Fraud filed 94 criminal cases for fraud. During
that same period, 65 individuals were convicted. To avoid encouraging a risk/benefit
analysis, it should be noted that this disparity is due to the pendency of the remaining
criminal cases. Zero individuals were acquitted during this time period. Over six
million dollars was paid in criminal restitution and defendants paid $267,854,037
in civil monetary recoveries. I would hope that these folks would no longer agree
that "Greed works."
For those who still might abide by Gordon Gekko's words, consider the myriad of
agencies in addition to, or in conjunction with, the Medical Board, that investigate
allegations of fraud: the state Department of Justice (Bureau of Medi-Cal Fraud
and Elder Abuse), the Federal Bureau of Investigation, the Office of the Inspector
General, the Department of Health Services, the Department of Insurance, to name
but a few. Additionally, most large insurance companies have in-house investigation
units dedicated to the problem of fraud. Greed may "Capture the essence of the evolutionary
spirit," but it also inspires the tenacity of the just spirit, because greed impacts
all of us personally. Our tax rates increase, our insurance premiums increase, our
deductibles increase because of the huge losses a few greedy people impose on all
of us.
Fraud cases often come to our attention after a physician has been convicted. That
investigation process was described in detail for the "sin of anger" article (Medical
Board Newsletter, April 2007). Sometimes the Medical Board receives a complaint
from an insurance company, or a tip from an anonymous employee, and we work up the
fraud case ourselves. For example, the Glendale police department once called a
district office to report they had responded to a call and found an office filled
with hundreds of medical charts, in varying phases of construction, being prepared
for submission to Medi-Cal for false billings. Bad people sell patient identifying
information and from that, data is derived to submit false claims.
Then there is the kind of greed involving physicians who receive kickbacks from
laboratories or entities selling medical devices. Or there is the physician who
performs one level of service but bills for a much higher level. There is "unbundling,"
where the physician bills for a number of services, individually, when the services
are customarily billed as one global service. There are physicians who perform unnecessary
procedures. A particularly egregious recent case involved an interventional cardiologist
whose fraudulent test interpretations caused patients to undergo coronary bypass
procedures. There are physicians who employ staff to travel around large cities
to pick up indigent "patients." These folks are driven to a doctor's office where
numerous unnecessary tests are run and unneeded medical services are provided and
billed to Medicare or Medi-Cal. The patient is provided a meal, or a fruit basket,
or $20. Hopefully they're returned to the same place from where they were extracted,
but sometimes we receive complaints that they were abandoned and had to find their
way back home.
There are drug cases that straddle greed - the physician who charges a fee for a
prescription. Never mind the appropriate prior examination or medical indication:
if you've got $50, you can have a prescription for #30 Vicodin. The Internet has
become a popular medium for greed. Apparently cyberspace does not discriminate between
men and women because most of us have been inundated with electronic mail from entities
proffering erectile dysfunction medications. And I know most of you never look at
the back of this publication to see who's been disciplined, but if you go back a
year, you'll note an increasing number of doctors finding themselves in trouble
for Internet prescribing.
Mix greed with vanity and you might have an explanation for the cosmetic and Lasik
surgery booms. Physicians who were trained in other specialties see the quick money
in Lasik surgery or an untapped market in bariatrics. Many cosmetic surgeons and
hair transplant physicians hire "counselors" or "assistants" to screen prospective
patients with strong-armed sales techniques reminiscent of the stereotypical used
car salesman.
Mix greed with sloth and a dash of insanity, and you might understand the motivation
for the three doctors who were successfully prosecuted because they substituted
saline for flu vaccinations. Or the ones disciplined for using non-pharmaceutical
grade Botox to save a buck or two. Or the ones disciplined for disposing of hazardous
waste in conventional trash bins; or of throwing away patients' records because
proper disposal costs too much money. Physicians have fabricated clinical study
records in pharmaceutical trials. In these circumstances, I would be less inclined
to agree that "Greed clarifies."
Mix greed with dishonesty, and you might discover someone like this physician —
the one engaged as an expert witness who will say whatever the hiring attorney wants
if the price is right. Within the last year, at least one physician was disciplined
for dishonesty in testifying as an expert. I suspect we'll be seeing a lot more
of these cases since greed also seems to beget litigiousness.
Mix greed with naivete or financial desperation and you might happen upon a disturbing
trend we've been seeing the past five years or so. A large number of newly licensed
physicians and elderly physicians are being hired to "front" clinics that are actually
owned and operated by lay people. Some of this involves sophisticated organized
crime rings, and physicians become unwitting victims when they align with a shrewd
lay person who promises a steady and generous paycheck, an office, and a source
of patients. These lay people masquerade as business managers, but physicians constructively
become the layperson's employee, or should I say puppet, which translates into the
unlicensed practice of corporate medicine. The layperson utilizes the physician's
license to commit fraud. Often, once the physician realizes what's happening, and
tries to exert control, they are locked out of the practice, or left fearing for
their safety when they realize the gravity of what is happening with their license
and want to get out of the situation. It seems newly licensed physicians are especially
vulnerable to this scheme because of oppressive student loans and business naivete.
Elderly physicians who really should have retired from the practice, but have not
properly planned for retirement, are also easy marks for this form of fraud. (More
information about the prohibition against the unlicensed corporate practice of medicine
can be found in the April 2004 issue of the Action Report, page 4. You
can review it on the board's Web site at
www.mbc.ca.gov/Download/Newsletters/action-report-2004-04.pdf.
And finally, I cannot omit corporate greed as it epitomizes this sin: you know,
the physician who is penalized for not seeing enough patients in a given time period
so billings can be maximized? Or the paradox of this situation - the physician who
purposely over schedules him or herself to the point that laboratory results are
missed and not acted upon, or other lapses in good medicine occur.
Maybe it is true that greed has marked the "upward surge of mankind," but at whose
expense? In these egregiously greedy times, it's hard not to jump on the Avarice
Express, but hopefully the aforementioned scenarios, not to mention the fate of
Gordon Gekko, will lead you to conclude that "Greed, for lack of a better word,"
is dangerous.
Coming up next: Pride.