As a small, private practice in Boston, we have needed to opt out of most insurances, one of those being Medicare. As our healthcare system has evolved, increasing health insurance restrictions make it harder, not easier, to treat all types of patients. In order to continue providing high-quality care as an ambulatory hernia clinic, we opted to remove the red-tape, and operate out of network.
Yesterday, 3 years after we made that decision, Boston Hernia received our first Medicare audit.
For those unfamiliar, a Medicare audit is essentially Medicare demanding the money back for surgery they already have paid for; because they believe you may have committed fraud with your level of care.
Being direct, a Medicare audit is one of the worst things that can happen to your practice. Your choices are:
Either return the money, or fight it – which requires time, documentation, and effort, all of which pull focus away from patient care.
After reviewing the document, we were shocked when we realized Medicare was challenging only one patient.
The story:
Shortly before I opted out of Medicare, we treated an elderly man with a recurrent inguinal hernia. His first two repairs were performed at a major Boston teaching hospital using a plug and patch… a method we do not use due to its high complication and recurrence rate. The first repair failed almost immediately. The surgeon then used another plug, which also failed.
I accepted him as a new patient, suspecting one thing: his hernia repair was most likely going to be complex.
That proved to be true.
The fast recovery inguinal hernia repair typically takes 45 minutes to complete. Two hours into this case, I had to call in my partner, Dr. Fullington. The previous mesh plugs had migrated and were attached to his intestines. Together, we spent over four hours removing the migrated mesh plugs, preserving the intestine, and repairing the current hernia.
Given the complexity and long operative time, I processed and billed the repair at a slightly higher level. In regards to insurance, a more complex surgery = more $.
Now, years later, Medicare claims the charge was fraudulent, and wants the money back.
So, what?
Well, this patient isn’t an isolated issue. Rather, this story, from failed hernia repairs to a Medicare audit, is representative of our failing healthcare system.
First and foremost, the foundation of medicine is providing compassionate, appropriate care to patients. A plug and patch hernia repair? That doesn’t cut it. Plug and patch repairs lead to chronic pain, “mesh migration”, infection, and hernia recurrence. Throughout my time as a hernia specialist, I have honed my skills to repair hernias in a way that decreases the chance of chronic pain, allows patients to get back on their feet faster, and eliminates the need for general anesthesia and opioids. I have not used a plug to repair a hernia in almost 20 years.
Secondly, this case highlights the injustice with insurance companies. This audit didn’t happen because I provided poor care or because I “stole” money from Medicare. It was simply flagged because it cost Medicare slightly more than the average. That alone speaks volumes about how broken our system is- where money is more important than high quality care. It also represents one of the many reasons why we elected to opt out of most insurances. After providing life changing care, we still were saddled with endless paperwork and rebuttals against Medicare.
Moving Forward:
Honestly, I’m not sure where the future of medicine lies.
We have seen the shift in larger cities like New York City, and now in Boston. It started with direct primary care and now direct speciality care. Like those before us, in opting out of insurance, we are able to focus entirely on providing quality care to our patients.
Our mission at Boston Hernia has always been simple: to provide superior clinical outcomes with exceptional patient and employee experience in ambulatory hernia care.
Insurance audits, outdated repair methods, and arbitrary billing rules do nothing to advance patient care. So, as always, we will continue to operate outside that system and focus entirely on what matters: effective, compassionate care of our patients.