the RUC: One Price to Rule Them All

[c1ue]

http://www.washingtonmonthly.com/mag...deal045641.php

On the last week of April earlier this year, a small committee of doctors met quietly in a midsized ballroom at the Renaissance Hotel in Chicago. There was an anesthesiologist, an ophthalmologist, a radiologist, and so on—thirty-one in all, each representing their own medical specialty society, each a heavy hitter in his or her own field.

The meeting was convened, as always, by the American Medical Association. Since 1992, the AMA has summoned this same committee three times a year. It’s called the Specialty Society Relative Value Scale Update Committee (or RUC, pronounced “ruck”), and it’s probably one of the most powerful committees in America that you’ve never heard of.

The purpose of each of these triannual RUC meetings is always the same: it’s the committee members’ job to decide what Medicare should pay them and their colleagues for the medical procedures they perform. How much should radiologists get for administering an MRI? How much should cardiologists be paid for inserting a heart stent?

While these doctors always discuss the “value” of each procedure in terms of the amount of time, work, and overhead required of them to perform it, the implication of that “value” is not lost on anyone in the room: they are, essentially, haggling over what their own salaries should be. “No one ever says the word ‘price,’ ” a doctor on the committee told me after the April meeting. “But yeah, everyone knows we’re talking about money.”

Much more at link...

So. it turns out the US has a similar committe as Japan does, which determines what a fair price should be for any given medical service.

Unfortunately the US one doesn't seem to operate the same way...

[lektrode]

Re: the RUC: One Price to Rule Them All

apparently its still quite possible for some to charge just about anything they feel like - to the tune of 10 million, over a period of years - regardless of whether the patient even needs anything remotely like the stuff billed for??

caught/saw this lil beauty on the pbs nightly biz report the other night:
Long Island Health Care Provider Sentenced to 12 Years in Prison for $10 Million Medicare Fraud and Hipaa Identity Theft

FOR IMMEDIATE RELEASE
April 10, 2013
Defendant Stole Patient Records From Nursing Homes To Create And Submit False Medicare Claims

Earlier today, Helene Michel, an owner and officer of Medical Solutions Management, Inc. (“MSM”), was sentenced to 12 years in federal prison by United States District Judge Joseph F. Bianco at the federal courthouse in Central Islip, New York. Michel was convicted after a three-week jury trial in August 2012 of conspiracy to commit health care fraud, health care fraud, and HIPAA identity theft crimes. At today’s sentencing, Judge Bianco also ordered that Michel forfeit $1.3 million that was seized by the government at the time of her indictment.
The sentences were announced by Loretta E. Lynch, United States Attorney for the Eastern District of New York, Thomas O’Donnell, Special Agent in Charge, United States Department of Health & Human services, Office of Inspector General, Office of Investigations (“HHS OIG”), and George C. Venizelos, Assistant Director in Charge, Federal Bureau of Investigation (“FBI”), New York Field Office.
According to the evidence at trial, between approximately April 2003 and March 2007, Helene Michel owned and operated MSM, a medical equipment company located in Hicksville, New York. Michel used her position as a medical equipment company owner to enter nursing homes in Nassau, Suffolk, Queens, Kings, and Dutchess Counties in order to access and steal patient records, in violation of the Health Insurance Portability and Accountability Act (“HIPAA”). During the scheme, Michel also falsely assumed a number of roles, including posing at various times as a doctor, a nurse practitioner, and a wound care expert. At times, in her false roles, Michel even accompanied doctors on patient evaluation rounds. Thereafter, Michel used the records that she stole to create and submit $10 million in false billings to Medicare for medical supplies and products that were either not required or not delivered. For example, in one instance, Michel used fraudulent drawings and measurements to support a Medicare claim for the cost of fitted boots for a legless patient. In another, Michel submitted false claims for the purchase of expensive wound care bandages to treat patients who never had such wounds. In the event that Medicare denied an MSM claim, Michel submitted an appeal of the denial supported by additional stolen and altered patient records.
Michel spent the Medicare funds that she stole through false claims and identity theft on her own personal interests, including a multi-million dollar home on Long Island’s North Shore, a half-million dollar pension account, and personal items such as luxury cars and designer handbags. Michel’s co-defendant Etienne Allonce, the co-owner of MSM, was also charged in the indictment and is believed to have fled from the United States. He remains a fugitive, listed on HHS OIG’s Most Wanted List.
“Helene Michel brazenly roamed the halls of dozens of nursing homes, pretending to be, among other things, a doctor, a nurse practitioner, and a wound care expert, even going so far as to join patient evaluations. In reality she was a con woman, deceiving patients and administrators alike as she trolled for the information she used to submit fraudulent claims to Medicare to support her extravagant lifestyle. Through her scheme she violated the privacy of over a thousand patients and stole Medicare funds dedicated to preserving the health of our seniors and other citizens,” stated United States Attorney Lynch. “We and our law enforcement partners will vigorously pursue and prosecute those who seek to profit by such despicable crimes.” Ms. Lynch expressed her grateful appreciation to HHS OIG, the FBI, and the Nassau County District Attorney’s Office.
The government’s case was prosecuted by Assistant United States Attorneys Charles P. Kelly and Burton T. Ryan, Jr.

among other stuff mentioned on the NBR - she and her hubby, who fled the country - were livin quite large, 'drove a big mercedes' and were shacked up in a multimillion dollar long island pad she bought with 'the profits'.

guess she'd been learning 'the trade' from from some of her neighbors out there on The Island, eh?
apparently she dont have the same friends at the dept of 'justice' that they do...