Medicare Fraud and Abuse

Medicare fraud costs the US government billions of dollars every year and is an area in which they are only too aware that reforms need to take place. The Medicare program is a great scheme that provides insurance coverage for millions of American citizens but on the downside it leaves itself open to fraud and abuse because of its sheer size and poor management.

The Medicare program offers cover for hospital and medical insurance, prescription drugs as well as entitlement to Medicare advantage plans and these are all areas in which unscrupulous individuals and companies are ripping off the government.

So what is Medicare fraud and abuse?

Fraud occurs when Medicare is billed for services or goods that were never carried out or received.

Abuse takes place when doctors or suppliers fail to conduct good medical procedures that result in unnecessary costs to Medicare, illegal payments, or medical procedures that weren't even necessary.

Why does this affect me?

You may be inclined to shrug your shoulders and think that such fraud and abuse doesn't concern you, but you'd be very wrong. Whilst the onus is on the government to provide the funding for Medicare, it falls to the American taxpayer to make up any shortfalls. The government are trying to juggle balls and keep them all in the air, but in reality they have to cut back on services in other areas that may also affect you, the taxpayer.

What can be done?

The government is actively trying new ways of cracking down on this ever growing problem and are trialling such things as palm scanners which help to identify patients, rendering it impossible for a fraudster to pretend to be someone else in order to get medical treatment and drugs. They are also introducing computer technology that is able to highlight individuals or companies who could be potentially committing Medicare fraud.

They also rely heavily on individuals to report on fraud within the workplace. It may be that as a doctor's receptionist you are aware that double billing is occurring on a regular basis or that time sheets are being tampered with or even being submitted for employees who don't exist.

If you have any knowledge that fraud is happening right under your nose, then you need to report it to the relevant authorities. There are some stipulations before you can effectively blow the whistle and these are:

• the fraud needs to be original information
• you must not have planned the fraud
• the amount of money involved in the alleged fraud needs to be in excess of $1 million and

in excess of $2 million in some states.

So what's in it for me?

To be seen to be telling tales is never a good position to be in, but there is the moral issue of doing the right thing as opposed to letting others blatantly fleece the government. What's more, the government offers a financial incentive in that if a case is successfully proven, then the whistleblower will be entitled to a share for their part in reporting the fraud. This can be up to 30% of the total amount of the fraud, which when millions of dollars are involved, could be a tidy sum in your pocket.

Identity theft

Identity theft is another worrying issue for all Medicare patients who may have their personal details stolen, which could result in them becoming ineligible for treatment, being given the wrong treatment, or even being left in debt.

It pays to be vigilant and guard your Medicare details with as much care as you would your credit card. For example:

• Never divulge your insurance number to anyone on the phone unless you have a prior arrangement with them and are receiving treatment from them.
• Always fill out your forms one at a time and date and sign each one individually. If a doctor talks about tests and procedures, ask him what they are for and how much they cost.
• Mark the date on a calendar when you receive any treatment and always keep receipts and statements so that you can check for any mistakes.
• Use this information when checking Medicare claims to ensure that neither you nor Medicare was billed for any services or items that you didn't receive.

Medicare fraud affects us all but everyone can do their bit to fight back against the fraudsters by having the courage to blow the whistle and be more vigilant.