Medicare - False Diagnosis ??

[LakeRat1]

Curious if this is a big deal or not?? .... We moved to a different county in Florida, thus we had to find new Drs..... My DW is 70 years old, went to the doctor for a check-up and blood work. (She is a retired nurse) After looking looking over the order for lab work, she noticed that there was a diagnosis checked stating Chronica Kidney Disease, .... Since she questioned the Dr. at her visit, the Dr told her, its normal, that it does not matter even though she has never had any abnormal lab tests. As well, she scheduled her for her next visit for one year. The lab order for next now has Chronic Kidney Disesase Stage 2. She told her this normal practice ....... I think Medicare get paid more $$$ per diagnosis.....? Is this not medicare fraud, or do others at this age see this same diagnosis for no reason ??

 

[MichaelB]

Not sure about the law, but this deliberate mis-coding is sketchy and certainly unethical.

 

[LakeRat1]

When questioned, the Dr said the diagnosis does not mean anything. I find that very hard to believe and I am thinking, Medicare is probably paying more to this Dr for this diagnosis, even though my DW has no symptoms, nor does any blood work show any abnormalities ..... Hmm

 

[braumeister]

In her shoes, I would consider this:
Reporting Medicare fraud & abuse

 

[Teacher Terry]

It’s fraud and I would find a different doctor.

 

[Silver]

Since she is a retired nurse I'm sure she knows her glomerular filtration rate (GFR), and probably trends them in order to accurately assess her ongoing kidney function. We all have chronic kidney failure as we age. Most of us just don't live long enough to die from it. I think it's more of a terminology issue then clinical issue.

GFR naturally declines as we age, and since they are clinically categorized by lab results, it could be that she has just naturally moved into another stage. As per the National Kidney Foundation, stage 2 is actually very good.

https://www.kidney.org/kidneydisease/siemens_hcp_gfr

My guess is that this is just a normal documentation of the aging process, with nothing negative intended at all. But I guess it depends on her most recent GFR.

 

[MichaelB]

When questioned, the Dr said the diagnosis does not mean anything. I find that very hard to believe and I am thinking, Medicare is probably paying more to this Dr for this diagnosis, even though my DW has no symptoms, nor does any blood work show any abnormalities ..... Hmm

Codswallop. I wonder what an insurance company would say about a diagnosis of kidney disease. A diagnosis always means something.

It’s safe to assume if this physician does it with you they do it with others. I would report to Medicare, not as fraud, but just something that merits further investigation.

 

[aja8888]

Since she is a retired nurse I'm sure she knows her glomerular filtration rate (GFR), and probably trends them in order to accurately assess her ongoing kidney function. We all have chronic kidney failure as we age. Most of us just don't live long enough to die from it. I think it's more of a terminology issue then clinical issue.

GFR naturally declines as we age, and since they are clinically categorized by lab results, it could be that she has just naturally moved into another stage. As per the National Kidney Foundation, stage 2 is actually very good.

https://www.kidney.org/kidneydisease/siemens_hcp_gfr

My guess is that this is just a normal documentation of the aging process, with nothing negative intended at all. But I guess it depends on her most recent GFR.

I'm 80 and have never had a Dr. record that after my lab work comes in and I can't believe my kidney function is at the top of the charts.

 

[LakeRat1]

Since she is a retired nurse I'm sure she knows her glomerular filtration rate (GFR), and probably trends them in order to accurately assess her ongoing kidney function. We all have chronic kidney failure as we age. Most of us just don't live long enough to die from it. I think it's more of a terminology issue then clinical issue.

GFR naturally declines as we age, and since they are clinically categorized by lab results, it could be that she has just naturally moved into another stage. As per the National Kidney Foundation, stage 2 is actually very good.

https://www.kidney.org/kidneydisease/siemens_hcp_gfr

My guess is that this is just a normal documentation of the aging process, with nothing negative intended at all. But I guess it depends on her most recent GFR.

Her GFR is currently and has always been within the normal range between 60 & 80...... Why would the DR document this as a diagnosis...... Never before has this been done with my DW....... This is why I am asking if other have seen this practice ..... I did find out that Medicare does pay more for each diagnosis ..... Is this Fraud

 

[LakeRat1]

It’s fraud and I would find a different doctor.

She is getting a new DR, this is not ethical at all...... I want to her to call the Medicare hot-line and discuss with them .....

 

[Teacher Terry]

She is getting a new DR, this is not ethical at all...... I want to her to call the Medicare hot-line and discuss with them .....

I hope she’s willing to report this. I wouldn’t want a diagnosis that I didn’t have as in an emergency at the hospital it could affect how they treated her, what medication they gave, etc. I have never had a doctor do this.

 

[Silver]

Again, it may just be a misunderstanding of terminology.

A GFR between 60 & 80 is not "normal". It is stage 2 of chronic kidney disease. And it's fine for a person her age. In fact....it's very, very good.

Different health care providers use different terminology, but using stage 2 chronic kidney disease (CKD) to describe a GFR is not uncommon. I understand it's new to you, and I regret that the physician did not do more to explain it.

Could the physician be using that terminology to gain an advantage in reimbursement? I have no idea. But for a GFR between 60 & 89, the American Kidney Foundation defines that as stage #2 CKD. And any health care provider reading that would understand that her kidney function is excellent.

 

[MarieIG]

Again, it may just be a misunderstanding of terminology.

A GFR between 60 & 80 is not "normal". It is stage 2 of chronic kidney disease. And it's fine for a person her age. In fact....it's very, very good.

Different health care providers use different terminology, but using stage 2 chronic kidney disease (CKD) to describe a GFR is not uncommon. I understand it's new to you, and I regret that the physician did not do more to explain it.

Could the physician be using that terminology to gain an advantage in reimbursement? I have no idea. But for a GFR between 60 & 89, the American Kidney Foundation defines that as stage #2 CKD. And any health care provider reading that would understand that her kidney function is excellent.

Agree that if this is the case - her doctor should explain that to her as clearly as you did.

 

[youbet]

Curious if this is a big deal or not?? .... We moved to a different county in Florida, thus we had to find new Drs..... My DW is 70 years old, went to the doctor for a check-up and blood work. (She is a retired nurse) After looking looking over the order for lab work, she noticed that there was a diagnosis checked stating Chronica Kidney Disease, .... Since she questioned the Dr. at her visit, the Dr told her, its normal, that it does not matter even though she has never had any abnormal lab tests. As well, she scheduled her for her next visit for one year. The lab order for next now has Chronic Kidney Disesase Stage 2. She told her this normal practice ....... I think Medicare get paid more $$$ per diagnosis.....? Is this not medicare fraud, or do others at this age see this same diagnosis for no reason ??

You may find that without the diagnosis some of your DW’s blood work or other tests are not covered by Medicare. Screening tests frequently aren’t. But paying for these things yourself is the right thing to do so report and show this doc you want things done the right way.

Sadly, physicians coding what in reality are “check-ups” (not covered) get flexible to save patients money with Medicare.

 

[badatmath]

Her GFR is currently and has always been within the normal range between 60 & 80...... Why would the DR document this as a diagnosis...... Never before has this been done with my DW....... This is why I am asking if other have seen this practice ..... I did find out that Medicare does pay more for each diagnosis ..... Is this Fraud

That is NOT the normal range for GFR.

I believe mine was 106 or perhaps 116. The tests that you get at your PCP are not nearly as specific as what a nephrologist will do and their tests will provide better information. I don't really remember since mine were all normal but they check things like protein in urine and so on as well. I had both blood and urine tests at the nephrologist yet a PCP has only done blood work.

It is likely they said it doesn't matter because stage 2 is not treated.

I don't recall more details from my visit as I did not have any of the issues they were checking for but I think that could be where the confusion is coming from.

Apologies as I see posters before me explained this and did a better job.

 

[plsprius]

This doesn't look like Medicare fraud, but rather not enough time taken to explain the blood work to the patient. Still poor doctoring...

According to Dr. Google (and https://www.kidney.org/atoz/content/stages-chronic-kidney-disease-ckd), chronic Kidney Disease (CKD) is a condition where the kidneys become damaged over time and struggle to perform their essential functions. It’s crucial to understand the stages of CKD to guide treatment decisions. Let’s dive into the kidney journey:

Stage 1 CKD: At this early stage, your estimated glomerular filtration rate (eGFR) is 90 or higher, indicating normal kidney function. However, there’s evidence of kidney damage (such as a urine albumin-creatinine ratio [uACR] of 30 or higher) lasting for at least 3 months.

Stage 2 CKD: Kidney function remains relatively good (eGFR between 60 and 89), but there’s still evidence of kidney damage (uACR of 30 or higher) over an extended period.

Stage 3a CKD: Here, you experience mild to moderate loss of kidney function (eGFR between 45 and 59) for at least 3 months.

Stage 3b CKD: The loss of kidney function becomes more pronounced (eGFR between 30 and 44). It’s essential to monitor your kidney health closely at this stage.

Stage 4 CKD: Severe loss of kidney function (eGFR between 15 and 29) characterizes this stage. Medical attention and management are critical to slow down further decline.

 

[Letj]

When questioned, the Dr said the diagnosis does not mean anything. I find that very hard to believe and I am thinking, Medicare is probably paying more to this Dr for this diagnosis, even though my DW has no symptoms, nor does any blood work show any abnormalities ..... Hmm

The same thing happened to a friend of mine on Medicare and the doctor told her don’t worry about it because her kidney function is fine for her age. She is fine for her age.

 

[donheff]

Interesting thread. I would be (or now maybe would have been) shocked to see that phrase appear on my medical records without a clear discussion. Any doctor who just tosses stuff like this out without explanation disserves to be reported for fraud just to catch his or her attention.

 

[oldtrig]

I would say no big deal. I am 76 and mine has been between 60 and 80 for the last fifteen years. Last month it was 80.

 

[Aerides]

Curious if this is a big deal or not?? .... We moved to a different county in Florida, thus we had to find new Drs..... My DW is 70 years old, went to the doctor for a check-up and blood work. (She is a retired nurse) After looking looking over the order for lab work, she noticed that there was a diagnosis checked stating Chronica Kidney Disease, .... Since she questioned the Dr. at her visit, the Dr told her, its normal, that it does not matter even though she has never had any abnormal lab tests. As well, she scheduled her for her next visit for one year. The lab order for next now has Chronic Kidney Disesase Stage 2. She told her this normal practice ....... I think Medicare get paid more $$$ per diagnosis.....? Is this not medicare fraud, or do others at this age see this same diagnosis for no reason ??

I don't know if it's fraud or slopping records, but did DW say "Well, before we do anything else you must correct that, and I'd like my records updated, or I find another doctor."

Or did she just take their explanation? I know it's hard to stand up for oneself in medical settings, but it's important to remember you are a Customer first, and Patient second, and vote with your dollars and feet when warranted.

ETA: I would give them the opportunity to make a swift correction, but if that didn't pan out, then I'd report it. But first, let them know and ask for it to be fixed.

 

[single2019]

Curious if this is a big deal or not?? .... We moved to a different county in Florida, thus we had to find new Drs..... My DW is 70 years old, went to the doctor for a check-up and blood work. (She is a retired nurse) After looking looking over the order for lab work, she noticed that there was a diagnosis checked stating Chronica Kidney Disease, .... Since she questioned the Dr. at her visit, the Dr told her, its normal, that it does not matter even though she has never had any abnormal lab tests. As well, she scheduled her for her next visit for one year. The lab order for next now has Chronic Kidney Disesase Stage 2. She told her this normal practice ....... I think Medicare get paid more $$$ per diagnosis.....? Is this not medicare fraud, or do others at this age see this same diagnosis for no reason ??

The doctor put that diagnosis on the lab order to make sure that medicare covers your lab work

 

[Rianne]

My eGFR is 27. I am in the 4th stage of kidney disease. My Nephrologist diagnosed me with Polycystic Kidney disease which puts most on dialysis by the time I reach 70 yrs. old. I would kill to be in the 2nd stage. Kidneys gradually decline over the years. I hate they call stage 2 "Chronic Kidney Disease." It scares people. You do not need a Nephrologist until you reach late stage 3 and that can take years. Medicare did not even question my disease. The only thing Medicare is concerned about is end-stage kidney disease which is <=eGFR 15.

I went to the Mayo Clinic. I was misdiagnosed and do not have PKD, thanks to a genetic test. I thought I would have kidneys that weigh 20lbs and be on dialysis. I could have sued that Nephrologist but decided against it. The years of worry about a kidney transplant took a toll on me. Especially during Covid.

I don't consider myself an expert in kidney disease but I have researched extensively. Many people live long and productive lives with eGFRs below 20. Kidneys are an amazing organ. I'm at eGFR 27 and have no symptoms. None. That's one of the reasons I went to the Mayo Clinic. Thanks to my original Medicare with part G, I was able to do that with no authorization or hassle from Medicare Advantage. Mayo Clinic won't even take many Medicare Advantage plans. And it cost me nothing. I was able to talk with a highly regarded kidney specialist, known around the country.

Unless your kidney function drastically changes, no worries. It's gradual. It takes many months of blood tests to determine true kidney disease. GFR fluctuates. One month you might be eGFR 50, the next test you could be eGFR 60.

When your kidneys decline, watch salt and potassium intake. Drink lots of water +60 oz. Just take care of yourself. I would not have known I had kidney disease if not for the bloodwork. Many people don't find out they have end-stage kidney disease until the last minute when they're in the emergency room.

 

[Yipper]

This needs to be reported - as do all questionable billing/coding related to Medicare. There is an organization called the "Senior Medicare Patrol" (SMP) funded by CMS to help beneficiaries prevent, detect and report healthcare fraud, errors and abuse.

Start here: https://smpresource.org/ to find more information on active frauds and how to report on incidents in your state.

 

[RetiredHappy]

This is over reacting to "fake" diagnosis. Because Medicare and health insurance companies are such sticklers with the lab work that they would pay or not, medical offices prefer to err on the side of ensuring that the patients do not end up needing to pay for a test that is not covered.

I get lab work done every 6 months and this year I noticed that one of my diagnosis is listed as "anemia". I go way, what? I asked my doctor about it, and in 2022 I was in a serious accident with a large larceration to my liver 10 cm by 8 cm by 5 cm. I was anemic as my liver was bleeding out. In the hospital, my blood was taken every 6 hours to check on my CBC. I was admitted into ICU and stayed a couple of days because of my anemia. I had 5 broken ribs and I was told that they would not have admitted me just on that. It's my liver that they were concerned about. After I stablized, I was discharged while still anemic and that got into my PCP's records. I asked him about when I saw him earlier this month, and he said it is just a reminder to him that I had that medical issue.

99.99999999% of the doctors don't cheat with false diagnosis. It is often our own over reaction.

 

[plsprius]

Again, where's the fraud?

Consider the possibility that the earlier doctor missed the CKD, and it was the new doctor that caught it... eGFR 60 -89 is the beginning of CKD, and something to monitor for sure.