Patient Falsely Claims to Not Have Medicare. Doctor Goes to Jail.

Sounds absurd, doesn't it? And of course it really hasn't happened. Yet. As far as I know.

But it could happen in your lifetime. Here's how:

Patients regularly call my office asking whether I "accept Medicare." Until about a month ago we politely explained that I opted out of Medicare. This means the patient must agree in writing that neither of us will ever bill Medicare for services I provide and that the fee I charge is between me and the patient. We are not bound by the Medicare fee schedule. About a month ago, however, I decide to stop treating patients who are covered by Medicare altogether. (Why is another story.)

Many of the patients who call my office, when we tell them I do not accept Medicare, tell us they cannot find a psychiatrist in the area who does accept Medicare. The obvious solution? Lie. After all, what physician or office staff would suspect someone of claiming NOT to have coverage? What might we say? Prove it. I suspect not. And besides how could the patient prove he does not have Medicare coverage?

Why would a physician want to make sure the patient is not covered by Medicare? There may be stiff civil or even criminal penalties for failing to file a claim with Medicare unless the physician has opted out. So adopting a "Don't ask. Don't tell." approach involves considerable risk.

How would the patient know the physician does not accept Medicare patients, and thus must lie? My practice Web site front page clearly states that I do not accept patients who have Medicare.

I contacted the Office of Communications/Media Relations Group at Centers for Medicare & Medicaid Services and inquired whether any such cases have been prosecuted. Ellen B. Griffith, Public Affairs Specialist, responded:

"As to whether a physician would be prosecuted for failing to submit a claim for services to a beneficiary who lied about his status –  CMS is not an enforcement agency.  Prosecutions of violations of Medicare law are handled either by the Office of Inspector General or the Department of Justice.  I would suggest you contact them directly."

I then asked, "Is there a way a physician can confirm that a prospective patient is not a beneficiary by accessing a database at CMS or other agency?" So far no response.

I admit this hypothetical situation seems unlikely, but its very plausibility suggests Medicare badly needs fixing, and soon. You can join the conversation with seniors at AARP.