Literally and figuratively.
In August Wolfson, a distinguished service professor of public health, medicine and pharmacy, published an article in the Journal of the American Medical Association Dermatology entitled “Avoiding and Managing Medicare Fraud and Abuse Investigations of Mohs Surgery: Mohs in the Crosshairs.”
Mohs surgery is a dermatologic procedure used to treat certain skin cancers. After the area is anesthetized, both the cancerous lesion and a thin layer of surrounding skin are removed. More and more skin is removed until no more cancer is present in the sample.
In the article Wolfson notes that there was a 600 percent increase in the number of physicians billing Medicare for Mohs surgery between 2009 and 2016, while Medicare billings for the surgery increased 250 percent.
Mohs surgery is at risk for abuse because of the multiple layers of skin removed and biopsied. And the abuse is particularly rampant in Florida—a state with a lot of sunshine, an aging population and an abundance of skin cancer cases.
“Taking slices of the affected area is called staging,” Wolfson explained. “In most cases, there will not be more than two or three stages done. But a doctor who is taking four or five stages, or who is biopsing six or seven sites in one visit, might rouse the suspicion of the Department of Justice (DOJ).”
While the U.S. Centers for Medicare and Medicaid Services (CMS) and DOJ routinely scan the computerized files of the Medicare and Medicaid systems looking for red flags, Wolfson notes that many overzealous dermatologists are brought to the attention of investigators by disgruntled employees, fellow doctors/nurses and other whistleblowers.
“Over the past 20 years,” Wolfson noted, “non-Mohs trained dermatologists have gotten involved in the management and treatment of skin cancers, and, in so doing, have fallen victim to the tantalizing opportunity to make more money. They can end up charging for things they may not actually have done or that were clinically unnecessary. Among dermatologists in Florida, and Mohs surgeons in particular, the rates of performing unnecessary procedures, upcoding [assigning a wrong billing code to something to get a larger reimbursement] and even harming patients are high.”
Wolfson—who has both defended and prosecuted physicians in his private law practice—may have focused his research on dermatologists and Mohs surgery, but he’s quick to point out that Medicare fraud is a far-reaching problem.
“It’s seen in a lot of procedural-based clinical practices where there are surgeries or diagnostic processes with stages of complexities,” he said. “And, there has to be a predilection on the part of the practitioner to want to optimize revenue.”
Which brings Wolfson to his next research endeavor: looking at health care fraud in other medical practice areas, such as psychiatry and other surgical specialties.
“We’re collaborating with the DOJ and the federal court system, because judges would really like to have a landscape about what is being prosecuted and how those things turn out. Gathering and culling through the data is tedious, but it’s our next big project,” he said.
Story by Donna Campisano, USF College of Public Health
Tags: American Medical Association, Centers for Medicare and Medicaid Services, CMS, dermatologists, Dermatology, DOJ, Jay Wolfson, Medicare, Medicare fraud, Mohs surgery, skin cancer, US Department of Justice