Mismanaged Money in American Healthcare

Warren Buffett famously invoked the metaphor of a tapeworm when describing what healthcare is to the American economy. The United States spends approximately 20% of its gross national product on healthcare, but it is unclear where the money goes or who is minding the store. This healthcare crisis is mostly about money—not lack of money, but rather misspending of money.
From the perspective of a healthcare auditor and provider, this work describes the problems of American healthcare finance and proposes solutions. Extensive charts and graphs are used to trace where money goes in the American healthcare system, while other topics such as ethics in healthcare billing, un-auditable hospital costs and scams are discussed. There is evidence that clearly identifies where the money goes, and its destination may surprise the reader.

Lisa Famiglietti is a Texas–licensed speech-language pathologist (SLP) and audiologist. She has owned a private practice that bills private and public health plans for more than 38 years. She is the past president of the Independent Therapy Providers Association (ITPA), a nonprofit trade association comprised of private practice owners in Texas. She lives in Austin.

Mark Scott is an experienced healthcare auditor with more than 30 years’ experience in financial management and auditing. He has been an audit director for 22 years, audited health programs for 10 years, and was a Medicaid audit director for two years. He lives in Austin, Texas.

Lisa Famiglietti and Mark Scott
Format: softcover (6 x 9)
Pages: 229
Bibliographic Info: 42 photos, notes, index
Copyright Date: 2023
pISBN: 978-1-4766-8745-2
Imprint: McFarland

Introduction by Lisa Famiglietti 1
Tables, Charts and Maps 3
1. Death Rode a Pale Horse in 2020 5
2. The Medicaid Cluster 14
3. Where Does the Drug Money Go? 25
4. Money, Politics, and Data 34
5. Required Profits and MCOs 41
6. Coding and Billing 59
7. The Curious Case of CPT Code 92507 76
8. Curiouser and Curiouser 93
9. Managed Care Organizations: Down the Rabbit Hole 111
10. Regulations and Estimates 127
11. Regulation Failures: Third-Party Recovery and Site-Neutral Requirements 133
12. Cost-Shifting and the Flip and Roll 150
13. Scams with Teeth, Regulations without Teeth 156
14. Solutions for Unauditable Hospital Costs 169
15. Unnecessary Surgeries and Tests 183
16. Ethics in Healthcare Billing 189
17. Adding Up the Costs 199
Chapter Notes 205
Bibliography 217
Index 219