Avoiding and Managing Medicare Fraud and Abuse Investigations

by Willam Henghold, MD, FACMS

In their recent article in JAMA Dermatology, Wolfson, et al succinctly describe a growing area of concern for us Mohs surgeons: the threat of a government investigation into our practice.(1) Big brother is watching, and not just big brother, but our patients, colleagues, and medical organizations as well. And that is as it should be. Transparency is a good thing.

The subtitle of the article is “Mohs in the Crosshairs.” I don’t think this is a new problem. Mohs has been in the “crosshairs” for the entire time I’ve been in private practice (going on 15 years). And why is that? The answer is simple: the procedure is well reimbursed relative to other treatments for skin cancer specifically, and to other procedures across all specialties generally, and its use is increasing exponentially. I had one year in practice before the multiple surgery reduction rule hit Mohs surgery. And then there were the Mohs codes changes and other attempts to find ways to reduce reimbursement. This leads to a fear of the unknown for the future of the specialty. But I am proud to be a fellow of the American College of Mohs Surgery. It is an organization guided by smart, forward thinking, and fearless individuals who have always “leaned forward in the foxhole” and faced challenges head on.

Approximately 6 years ago I was asked by the Federal Bureau of Investigation (FBI) to help with a fraud investigation of a dermatology practice. This practice had become notorious in our community for a variety of reasons. The irony is that I had tried to help this practice several years prior and had previously warned them that they would be identified as an outlier if they didn’t stop performing Mohs surgery on actinic keratoses, among other things. I made an attempt to educate them. My warning fell on deaf ears, someone blew the whistle, and they were eventually raided by the FBI.

The financial burden of Medicare fraud is staggering: it is estimated to run in the range of $100 to $300 billion annually. And it’s just plain sickening. After reading the Wolfson, et al article I did a quick Google search (“Medicare fraud dermatology”) to see what I could find. Indeed, there are a number of dermatologists who have recently been found guilty of fraud and have paid huge fines and some who are currently in jail. I found it particularly interesting that all the dermatologists I read about were turned in by “whistleblowers,” several involved the use of superficial radiation therapy to treat skin cancer, and no one is/was a member of the Mohs College. But that doesn’t mean we aren’t all being scrutinized. Just assume we are. But that is OK. If you’re doing it right you should have nothing to hide.

There are three take-home points in all this: 1) don’t be an outlier, 2) pay attention to and support the specialty organizations who have our backs and ultimately those of the patients whom we serve, and 3) bill only for those services that are actually needed by the patient and performed by qualified and properly trained individuals. These points are touched on in the article by Krishnan, et al in JAMA Dermatology.(2) This paper nicely summarizes the efforts on behalf of the Mohs College Improving Wisely Study Group to identify outliers (defined as more than two standard deviations outside the mean) with respect to the number of stages performed for Mohs surgery (for CPT codes 17311 and 17312). We should all be aware of this and know where we stand. Six percent of those physicians performing Mohs surgery were identified as an outlier in at least one of the three years examined, and two percent were identified as outliers in all three years. Interestingly, those in solo practice were more likely to be identified as outliers. The surmised reasons for being an outlier range from ignorance and poor training to abject fraud. We would all like to think the very best of ourselves and our fellow colleagues and hope that all our efforts are well intentioned and directed at providing the very best care we can for our patients. The ACMS leadership takes this view, and rather than think the worst and publicly censure the outliers, our peer experts are privately engaging and educating them in an effort to help us all. The results of these efforts should be published soon. Let us hope it makes a difference.

As we move toward board certification for Micrographic Dermatologic Surgery, the process of getting all Mohs surgery providers on the same page, so to speak, will take up to five years. Initiatives such as the Appropriate Use Criteria, Improving Wisely Campaign, and board certification should all help to prevent unnecessary surgery and its associated costs. It stands to reason that this should reduce the abuse of the Mohs codes and with it any collateral risk of criminal investigation, except in cases of dishonesty. With continued education and support from the Mohs College and each other, I am confident that we will preserve the sanctity of the specialty we all hold so dear.