Saccoccio told me that while it’s hard to determine how common the intentional-misdiagnosis style of fraud is, the more typical variety is called “upcoding”: doing a cheaper procedure but billing for a more expensive one. (Awaad is accused of doing this, as well.) U.S. government audits suggest that about 10 percent of all Medicare claims are not accurate, though Malcolm Sparrow, a Harvard professor of public management, told me that’s likely an underestimate. He added that it’s not possible to know how many of these inaccuracies are false diagnoses, rather than other kinds of errors.
Sparrow speculated that doctors cheat the system because “they believe they won’t get caught, and mostly they don’t get caught.” There’s also the fact that doctors often do know more than their patients about various diseases. Sometimes, fraudulent doctors lord that knowledge over patients who get suspicious. In 2015, Farid Fata was sentenced to 45 years in prison for administering unnecessary chemotherapy to 553 patients. “Several times when I had researched and questioned his treatment, he asked if I had fellowshipped at Sloan Kettering like he had,” one of his patients, Michelle Mannarino, told Healthcare Finance.
Some lawyers argue that many of the doctors who get swept up in these kinds of cases are doing honest work: These doctors simply have a different opinion than another doctor who is later asked to review their diagnoses.