The Face of Medicare Fraud

Justice ServedWe don’t need an expert to tell us that fraud costs money.  Health care fraud costs the system money.  The irony is that we are the “system” – all of us who receive our health care services in the U.S. are victimized by fraudsters because they steal the resources that belong to us; resources that should legitimately go toward improving the care we receive.

As a small business owner, I feel the pain of paying my medical insurance premium, copays and related expenses.  It pains me more to hear that criminals are contributing to the rising costs.  But my pain turns to anger when I read of the ways fraudsters are taking advantage of the Medicare program designed to help the elderly and Americans with limited resources.  Seniors, facing high medical costs, are being forced to make choices that jeopardize their wellbeing.

This means that exposing and eliminating fraud is the business of everyone who cares about getting better and more affordable care.  The first step is to recognize what Medicare fraud looks like.

What is Medicare Fraud?

According to the U.S. Department of Health and Human Services (HHS), fraud schemes may be carried out by individuals, companies, or groups of individuals.  The HHS provides the following examples of possible fraud schemes:

  • A health care provider bills Medicare for services you never received.
  • A supplier bills Medicare for equipment you never got.
  •  Someone uses another person’s Medicare card to get medical care, supplies, or equipment.
  •  Someone bills Medicare for home medical equipment after it has been returned.
  •  A company offers a Medicare drug plan that has not been approved by Medicare.
  •  A company uses false information to mislead you into joining a Medicare plan.

This means that people involved in medicare fraud often look like the “real thing”.  The schemes are often elaborately set up to mimic legitimate health care service providers and involve a network of conspirators.

Recent Medicare Fraud Cases

As discussed in another article, under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS) acting through the Department’s Inspector General (HHS/OIG), the Health Care Fraud Prevention & Enforcement Action Team (HEAT) was created in 2009 to prevent fraud, waste and abuse in the Medicare and Medicaid programs, and to crack down on the fraud perpetrators.  The following are two recent cases resulting from the efforts of HEAT:

1.  The Houston Case:  On February 14, 2012, the Justice Department, the FBI and the HHS announced that two Houston-area nurses and two of their co-conspirators were sentenced to more than five years in jail for their participation in a $5.2 million Medicare fraud scheme.  According to the evidence presented at trial and in court documents, a Houston home health care company purported to provide skilled nursing to Medicare beneficiaries.  The company paid the conspirators to recruit Medicare beneficiaries for the purpose of filing claims with Medicare for skilled nursing that was medically unnecessary and/or not provided.  In addition to jail time, the four defendants were ordered to pay restitution jointly and severally with co-conspirators and defendants in a related case.  CLICK HERE for a copy of the press DOJ press release.

2. The California Case:  On February 10, 2012, agents from the FBI and Office of Inspector General (OIG) of the Department of Health and Human Services in the Northern California district announced the arrest of five defendants, including a medical doctor, for their participation in a fraud scheme involving more than $2.4 million in fraudulent Medicare billings.  The indictment alleges that from approximately Dec. 9, 2006, through July 26, 2011, two of the defendants, behalf of their companies, submitted more than $2.4 million in fraudulent claims for power wheelchairs to Medicare based on fraudulent prescriptions provided by the medical doctor.  The two defendants were paid more than $1.2 million by Medicare.  The indictment further alleged that two other defendants served as “recruiters,” identifying patients to receive the power wheelchairs and passing their names along to the doctor involved in the fraud scheme.  CLICK HERE for a copy of the press release.

You Can Stop Fraud

Remember, Medicare fraud affects every American. Waste, fraud and abuse take critical resources out of our health care system, and contribute to the rising cost of health care for all Americans.

You can help eliminate fraud and cut costs for us all (families, businesses and the federal government) by being vigilant.  Avoid becoming a victim.

If you suspect fraud, CLICK HERE to report it.

To learn more about health care fraud and government enforcement activity, read this article on this Blog.

©Rachel Agheyisi, Report Content Writer, and Regulatory Compliance Digest Blog, 2012

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2 Responses

  1. […] The Face of Medicare Fraud (regcompliance.wordpress.com) […]

  2. […] an earlier article on this blog, we presented examples of possible Medicare fraud schemes as identified by the U.S. […]

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