What’s a little fraud among friends? Medicare, Medicaid fraud enforcement

DoctorThere is a 31 year old Las Vegas, Nevada resident who recently pleaded guilty to two felony counts related to health care fraud. [LVSun] There were 100 prosecutable health care fraud cases in Nevada in 2012, that would be 100 too many.  The frauds come in a variety of manifestations: drug abuse, bogus claims, over-billing, identity theft, and staged “accidents and injuries.”  Some felony-minded souls appear to believe that a little fraud is allowable in order to reap a bit of reward from the burgeoning coffers of the health insurance corporations.  It isn’t.  The situation becomes unconscionable when Medicare and Medicaid are the targets of the fraudulent activities.

Last year saw some particularly egregious cases, such as the following:  “federal authorities announced on May 2 they had arrested 107 health care providers, including doctors and nurses, in several cities and charged them with cheating Medicare out of $452 million.”  [Forbes]

Speaking of Medicaid, in  April 2012 an Inspector General’s report for FY 2011 informed us:

In fiscal year 2011, MFCUs conducted 10,685 Medicaid fraud investigations and saw 824 convictions. MFCUs conducted 4,134 investigations into patient abuse and neglect, including patient funds cases, and saw 406 convictions. [FHC] *MFCU: Medicaid Fraud Control Units

The top five states for Medicaid fraud prosecutions were: California, Texas, New York, Ohio, and Kentucky.  [IG2012]  The report on Medicare wasn’t any more comforting:

Federal officials set up the Medicare Fraud Strike Force in 2007, which visited at random nearly 1,600 businesses in Miami, ground zero for Medicare fraud, that had billed Medicare for durable medical equipment.  Officials found that nearly a third of the businesses, 481, didn’t even exist, yet they had billed Medicare for $237 million over the previous year, according to National Public Radio. [Forbes]

Medicare and Medicaid aren’t functions of those ravenous profit centers otherwise known as the health care insurance corporations, thus even the dubious rationalization doesn’t apply.  That hasn’t stopped the fraudsters:

“Since their inception in March 2007, Medicare Fraud Strike Force operations in seven districts have obtained indictments of more than 825 individuals who collectively have falsely billed the Medicare program for more than $2 billion .  In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.”  [DoJ]

That’s the bad news, there is some good news to report on the subject of Medicare fraud:

“The Obama Administration has made important strides in reducing fraud, waste, and abuse across the government. Over the last two years, the Centers for Medicare & Medicaid Services (CMS) has implemented powerful new anti-fraud tools and designed and implemented large-scale, innovative improvements to our Medicare program integrity strategy to shift beyond a “pay and chase” approach to preventing fraud before it happens. CMS is also collaborating more with the private sector, law enforcement, and our state partners to harness best practices in our fight against health care fraud.

These efforts are paying off. In FY 2012, the government recovered a historic $4.2 billion and has returned a record-breaking $14.9 billion dollars to taxpayers between 2009 and 2012, up from $6.7 billion dollars over the prior four years.”  [DHHS]

We could happily note the improvement in Medicare fraud enforcement efforts and the returns that accrue to American taxpayers, BUT the House Republicans — in the “interest” of saving taxpayer dollars (and not raising taxes on millionaires and billionaires) — offer their “serious” budget proposal which transforms Medicare into a voucher/coupon program in which the Every Man For Himself policy extends into the health care insurance domain.

What could possible go wrong? Let us count the ways.  (1) Nothing in the GOP or Ryan Plan puts the brakes on the increases in health care costs — only in the individual’s remuneration for health care insurance costs.  There is no inducement in this proposal to reduce either the costs or the urge to game the system because of the mounting out of pocket costs.  (2) It is assumed that if Medicare as we know it is mutated into a privatized system that the fraud enforcement costs will be reduced at the federal level, which totally ignores the expenses incurred at the state levels wherein much of the anti-fraud activities take place.  (3) We cannot assume that the expenses involved in prosecuting national cases of interstate health care insurance fraud will be magically disappear by merely transferring the locus of funding — the Department of Justice might still exercise its authority to prosecute such cases — of course at public expense for the benefit of the health care insurance industry.

What we should be considering, in our own economic self interest, is the enhancement of funding for Medicaid Fraud Control Units, and the efforts to increase the effectiveness of the Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint project of the Department of Health and Human Services and the Department of Justice.

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