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Teaching Physicians About Fraud and Program Integrity

Lyles, Mark A. MD, MBA

doi: 10.1097/ACM.0b013e318299efc1
Commentaries

Program integrity (PI) is defined as a comprehensive strategy to prevent fraud, abuse, errors, and waste in the U.S. health care system. PI has the goal of eliminating improper payments for health care services. In 2012, the Institute of Medicine estimated that the U.S. health care system annually loses $765 billion to waste, including improper reimbursements for unnecessary services, excess administrative costs, inefficiently delivered services, egregious pricing of services, missed prevention opportunities, and fraud. The article by Agrawal and colleagues in this issue presents an excellent overview of the concerted efforts by the Centers for Medicare and Medicaid Services and other payers to ensure the integrity of the public and private health care reimbursement systems. Egregious examples of fraud and abuse are defined easily for physicians, and common administrative mistakes are rectified with better education in billing rules and documentation requirements. However, the more ambiguous areas of PI likely will remain difficult to address. With each episode of health reform, providers and payers are reminded of the current inefficiencies and inconsistencies under which the disparate reimbursement systems in the United States operate. Thus, it is increasingly important for physicians, payers, policy makers, product makers, and patients to collaborate and to collectively define and minimize waste in the U.S. health care system. This commentary reviews current challenges to educating physicians and physicians-in-training about PI and explores a PI education curriculum already in place at a large academic medical center that might serve as a model for other institutions.

Dr. Lyles is chief strategic officer, Medical University of South Carolina, Charleston, South Carolina.

Editor’s Note: This is a commentary on Agrawal S, Tarzy B, Hunt L, Taitsman J, Budetti P. Expanding physician education in health care fraud and program integrity.

Correspondence should be addressed to Dr. Lyles, Medical University of South Carolina, 250 North Tower, 169 Ashley Ave., MSC332, Charleston, SC 29425; telephone: (843) 792-0063; e-mail: lyles@musc.edu.

© 2013 by the Association of American Medical Colleges