Your Problem List, Your Safety and Medicare Fraud


For patients. 


Your “Problem List”.


Everyone that goes to their clinician today has one.


I’m not talking about the “reason you went to the office today.”  I’m talking about the list of active medical problems you’re under treatment for.


Didn’t know you had one?  You do.  And it’s very important you take control of it.


Why? Because it is possible for you and your problem lists to be used for fraudulent payments—without you ever knowing it! And the effects on your health could be terrible.


Your insurance company, the organization who employs your clinician and possibly the clinician herself all get paid, at least in part, based on what and how many problems are listed on your problem list. It doesn’t matter what type of insurance you have: commercial, employee, Medicaid, Medicare, Medicare Advantage—it’s increasingly true for all of them.  The more problems that are listed, the more money they collect. 


This makes sense: the more chronic illnesses you have, the more your care is going to cost, and the more resources are going to be needed to pay for those costs. When this system of payment is applied ethically, everyone’s interests are aligned. Medicare Advantage type of insurance makes the most of this alignment. That’s why, when done right, it works so well.


However, for those who are in it for a quick buck, it’s in their interest to lard your problem list up with every problem that can possibly be justified—and a few that can’t.


That’s right. Insurance companies are being investigated for simply making up medical problems in order to get more money from the government. 


And it wasn’t government investigators who found this out, it was whistleblowers from inside the organization reporting them.


The Escalating Tactics They Use:


At first, insurance companies sent letters to physicians, requesting confirmation of medical diagnoses based on their review of the medical record so they could send them to the government.  Later, those requests changed to simple notification that they were going to send those diagnoses into the government and they were doing the favor of letting the doctor know.  Then, they stopped contacting the doctor at all.  Lord knows what’s being submitted in your name.


You want your medical record to be accurate. With the fragmentation of care today, your medical record could be the only source of information your treating clinician has in an emergency.


Do you want to be unconscious in the ER with a mistaken diagnosis of diabetes on your chart? How about congestive heart failure?  Or emphysema?


You must assume that information is being put in your medical record all the time; by many, many folks–few of which you’ve ever seen.  And for most of them, the more information, the better it is for them.  Usually the better for you too—if it’s accurate.


Your strategy?


When you see your clinician for a routine visit, ask them to go through the list of active problems in your record—one by one.


Do this once a year. When you call to make the appointment, tell them that’s what you want it for.


Won’t do it? No time today? Ask what kind of dedicated appointment you have to set up in order to go through the list with you.


Still won’t do it? That’s an enormous sign that your clinician and her employer do not have the resources or interest to provide you the healthcare you deserve.


Fire them. Find another.


Easier said than done? Perhaps, but 1/3 of clinicians still work for themselves; they’re much more likely to be responsive.


Have access to an online “patient portal”? Check the problem list often, the first of every month.  If you find changes in the problem list, send a message to your clinician—ask them about it.  Often times, problem lists will change and no one will know how the change occurred. If the changes are wrong, insist that they are corrected–immediately. Keep checking until they are.


And when you make your yearly appointment, take a screen shot or write out a copy of the problem list and take it with you.  Use it as a reference as you both go down each problem one-by-one.


 Is all this a pain? Absolutely. But it’s the price we pay for the way our healthcare is being financed. No one is going to pay attention to your medical information as well as you.


You’re going to have to do it—to keep yourself safe, and to keep others from stealing in your name.


It’s in everyone’s interest to get as many problems on your list as possible.


The insurance company.

The health system.

The drug companies.



Everyone’s—except you.



Now you know.  What are you going to do about it?










I’m THE expert on all things Medicare Advantage and Managed Care Medicaid.  I’ve been a family physician for 25 years, helped create a multi-specialty group that cared for over a quarter-million souls and am absolutely not interested in selling you anything.

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