Everyone seems convinced there’s a ton of fraud in Medicare. And they may be right. What there wasn’t, for far too long, was much emphasis on finding and prosecuting the criminals stealing from taxpayers by defrauding Medicare.
Well, looks like that’s changed. This ‘story’ was first broken a week ago by Merrill Goozner, one of the more insightful observers of the health care scene. Here’s a piece from an OIG release quoted in Merrill’s post:
“Since their inception in March 2007, [CMS anti-fraud] Strike Force operations in nine locations have charged more than 1,000 individuals who collectively have falsely billed the Medicare program for more than $2.3 billion.”
CMS’ anti-fraud efforts are finally getting some press. For instance, prosecutions are up 85% over last year. Compared to five years ago, there’s been a 71% increase. It takes quite a bit of time to develop a prosecute a health care fraud case, as laws and regulations are quite complex and often confusingly contradictory; following the paper trail is difficult at best; and company ownership and fiduciary responsibility usually hard to identify and even more difficult to prove; thus it’s no surprise it’s taken a couple years for the Obama Administration to start to produce major results.
According to the piece in FierceHealthcare;
“The government prosecuted 903 cases of healthcare fraud, up 24 percent from last year, reports USA Today. The increased numbers come from more investigations under the close attention of the Federal Bureau of Investigation (FBI) and the Medicare Fraud Task Force, as well as the participation of whistleblowers. The FBI recently changed their focus to target criminal enterprises, including hospitals. In 2010, the government paid out $300 million to whistleblowers.”
Health care geeks may recall that the PPACA was supposed to deliver $4.9 billion in savings over ten years due to better controls over fraud and abuse. Looks like that was a ‘gimme’, as the GAO reported savings in 2010 alone were $4 billion.
These prosecutions often netted criminals defrauding commercial insurers as well as we taxpayers – one case in Puerto Rico nailed hundreds of crooks who stole $7 million from AFLAC.
Another CMS-led effort earlier this year resulted in indictments of 111 individuals for allegedly defrauding Medicare of $225 million.
That’s all to the good – perhaps as much for the ‘Sentinel Effect’ as for catching these thieves. Others who may be tempted to steal from the Feds or commercial payers may be a bit de-motivated when they hear about prison terms and hefty fines levied against others with the same idea.
There’s no question Medicare is a prime target for crooks large and small. After all, it’s a program that pays out billions each year, so there’s bound to be fraud. Commercial health plans, workers comp insurers, and other payers are certainly vulnerable and often victimized as well. Here’s hoping the recent press attention leads to even more attention on fraud, and more convictions as well.
What does this mean for you?
Are your SIU people tied into the CMS Strike Forces, sharing information and collaborating on investigations?
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