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COTA Thoughts

Healthcare Fraud and Abuse

Published May 31, 2013 9:40 AM by Tim Banish

News of fraud and abuse in our healthcare system appears frequently these days. Between scams, double billing and code jamming many dollars are illegally claimed from the system. Whether it be from Medicare, Medicaid or an insurance company, one thing is certain, the honest consumers pay for it.


Just recently the Medicare Fraud Strike Force hit eight cities and charged 89 people with billing Medicare $223 million in false claims. In some cities this was part of an organized scheme that included doctors, nurses and other licensed medical professionals. Much of the fraud included billing for services that were not needed or never occurred, home health visits that never happened, or durable medical equipment that was either unneeded or not provided.


Most large private insurance companies have their own fraud team who seek out false claims. In some states the fraud teams have the authority to impose fines, some have full police power. The latest (one year) statistics show nearly 5,000 convictions and $346 million recovered from fraud investigations.


One of the worst cases I discovered is the scheme to offer participants a free medical service in order to obtain their Medicare number. A patient recruiter would gather this information then the numbers would later be used in a billing scam. Using accounts of people who have passed away is also a frequently seen scam, and is not limited to just insurance. Some have used the accounts of dead people to collect Social Security, Workers Compensation or other services.


I remember a case from the early 1990's where a doctor was found guilty of Medicare fraud totaling $225 million. His was fined $2.5 million and barred from billing Medicare for 90 days. A very light sentence, as he still walked away with over $200 million. Today the fines usually amount to several times what the fraud totaled.


However this is part of why PPS came into play, fraud and abuse of the system. Even as the rules change and enforcement increases, there are some who can still find ways to cheat. As providers we are responsible to report any suspected fraud. Recipients must also play a big part in reporting fraud by scanning their medical bills for charges that are in error. I don't think insurance fraud will ever stop completely, but together maybe we can slow it down a bit.


Until next time, hope all your "Thoughts" are Good-



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