Zachary Sussman is a pathologist who oversaw covid tests at 4 standalone ERs for Physicians Premier, but he resigned in horror after he got a $8 covid test at one of the company's locations and then they billed his insurer $10,984.16 for it.
propublica.org/article/a-doct…
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propublica.org/article/a-doct…
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In an outstanding investigation for @propublica and the @TexasTribune, @marshall_allen reveals how both @MD_PremiER and @UHC - the nation's largest insurer - feed into this system of fraudulent price-gouging through a combination of greed and indifference.
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There are elements of this that are just straight-up fraud: the coding on Sussman's bill includes charges for procedures that simply were not performed, like an antibody test, an in-depth investigation, a problem-focused history, a nasal swab, etc.
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To make the fraud even more ghastly, Physicians Premier (and USA Emergency Centers, who license the name) overbilled for these procedures that were never performed: they charged $3200 for the nonextistent antibody test that they list at $75.
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The vast majority ($8,884.16) came in the form of a "facility fee," a major source of emergency care grift that crops up whenever private equity funds get involved in emergency care.
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When you hear about someone getting thousands in out-of-network fees for an icepack, that's almost always a "facility fee."
vox.com/health-care/20…
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vox.com/health-care/20…
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In this case, the fraud and facility fee were compounded by the fact that Physicians Premier/USA Emergency operate "standalone ERs" that are 100% out-of-network, meaning that they bill crazy sums that are either negotiated down by insurers or passed along to patients.
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The final component of this incredible fraud comes from Unitedhealthcare, the largest insurer in the country. They have been gouging like crazy during the pandemic, racking up $6.6B in earnings in Q2-2020 alone. This has drawn a ton of scrutiny and criticism, naturally.
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Which may explain why the company simply greenlit this obviously fraudulent charge (and why their internal fraud investigators were totally blase when Sussman called them up).
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They're making incredible, towering sums profiteering off the pandemic and sending it to shareholders and execs, rather than upgrading their creaking anti-fraud systems. They don't want to call attention to any of this and mess up their good thing.
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The CARES Act mandates insurers to pay for (many) covid tests, and the grossly inefficient, wildly profitable health-care system has used this as an excuse to gouge the grossly inefficient, wildly profitable insurance sector.
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Nobody (except plutes from the shareholder class) wins when these two giants wrestle one another.
The lesson of this awful scandal is that a broken, for-profit health-care system can't be fixed by mandating care.
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The lesson of this awful scandal is that a broken, for-profit health-care system can't be fixed by mandating care.
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Without a publicly accountable, public-spirited health care system, the CARES Act's mandate to pay for testing was just an invitation for the grossly unethical for-profit care system to gouge insurers.
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The exception to this is Medicare, which caps pricing for antibody tests at $42.13. Ironically, Sussman told Propublica he only came forward because he opposes Medicare for All and fears that abuses will give the existing system a bad name.
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"If instances like these go unchecked it will provide more ammo for advocates of a single-payer system."
Image:
Physicians Premier Austin
mdpremier.com/central-austin…
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Image:
Physicians Premier Austin
mdpremier.com/central-austin…
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