The Feds Need Elders to Help Stop Medicare Fraud

Article excerpt

Imagine a doctor who not only sees psychotherapy patients for more than 24 hours a day but also treats dead people with mental health problems.

Sounds like bad fiction. But this real doctor in Detroit submitted real bills to Medicare for these imaginary treatments.

It was fraud and he was indicted this past September, yet another criminal charged in the ongoing Medicare fraud saga that costs taxpayers billions per year. Nobody knows how much: the FBI estimates it could be 3 percent to 10 percent of all claims, which translates to between $15 billion and $50 billion.

Medicare has always worked to get the money out fast, pay the bills and keep doctors and patients happy. It's a daunting job to process more than a million claims a day.

But finally, as it's beset by a huge and ever-growing deficit, the federal government is getting more serious about fighting fraud. The Affordable Care Act (ACA) increases penalties for committing fraud, centralizes claims data to make it easier to detect crooked schemes and uses a central database to prevent firms banned in one state from shifting criminal activity to another.

Going After Big Fish

The biggest single "take-down" of Medicare crooks came in September 2011, when the feds arrested 91 people across eight cities, "including doctors, nurses, and other medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $295 million in false billing," according to the Justice Department and the Department of Health and Services (HHS), which runs Medicare.

There are now federal strike forcesjoint operations between Justice and HHS- in nine hot spots, where crooks are ingenious and their schemes proliferate: South Florida/Miami-Dade County, Los Angeles, Detroit, Houston, Brooklyn, Tampa Bay, Baton Rouge, Dallas and Chicago.

And there are lots of potential targets to keep these strike forces busy: doctors who prescribed drugs and never delivered them; doctors who looked into the rooms of multiple patients and then billed for a physical exam for each one; equipment providers who billed Medicare for penis-erection pumps provided to female patients or prosthetic arms and legs for patients with intact limbs.

Sometimes even the billing doctors are dead. "Medicare paid dead physicians 478,500 claims totaling up to $92 million from 2000 to 2007. These claims included 16,548 to 18,240 deceased physicians (U.S. Senate Permanent Committee on Investigations, 2008), according to the Coalition Against Insurance Fraud (www.insurancefraud.org/medicarefraud.htm).

ACA Empowers Preemptive Strikes

Under the new powers in the ACA, the government is going to take preemptive action, looking for abuse as Medicare bills flow in, just as credit card companies look for strange spending patterns. HHS says, "Medicare and state agencies will be on the lookout for trends that may indicate healthcare fraud- including using advanced predictive modeling software, such as that used to detect credit card fraud. …