What are the different types of Medicare fraud?
When a corporation or a person intends to receive Medicare health care reimbursements on a false pretense, it is known as Medicare fraud. In the United States, several cases of Medicare fraud have been reported in the last few years. The type of fraud may very but all of them have one basic aim – to illegally seek funds from various medical programs sponsored by the United States government. It is not easy to track the total losses incurred due to such frauds. Of all Medicare frauds, only a few are discovered and reported to the law enforcement agencies. Also, proving suspicious claims of fraud in the court of law is not an easy task. According to the recent reports from the Office of Management & Budget, total illegitimate funds allotted for Medicare funds amounted to over 47 billion dollars. Some of the claims in this bracket couldn’t be proven later on. During the year 2010, the total Medicare spending was around 528 billion dollars according to official records of the Congressional Budget Office.
Medicare programs are susceptible to fraud for a number of reasons. The prime reason contributing to these frauds is that the money under Medicare programs is allotted on the basis of a honor system. These programs were meant to assist medical professionals who wanted to help the needy in the society. Several safeguards have been introduced to minimize the total number of cases of false claims. As a matter of fact, payments for most claims are made automatically. It is done to make sure that honest doctors willing to help the needy through their medical services do not face any financial problems. Therefore, the process of payment against Medicare claims has been kept very smooth and hassle free.
Medicare fraud can be classified as follows:
- Fraud in phantom billing: In this case, a medical service provider claims funds for unnecessary medical procedures. Therefore, these funds are illegitimately sought from Medicare. A medical service provider may perform unnecessary procedures on patients in a healthcare institution or record tests and procedures that were never actually performed by doctors. Case related to the billing of old and used equipment as ‘new’ also falls under this category. Careful and systematic investigation procedures can be used to detect such phantom billing cases.
- Fraud in patient billing: in this case, a patient is also involved in the fraud. For example, a patient may provide his or her Medicare number to the medical services provider for vested interests. Generally, a patient receives kickbacks for such favors.
- Fraud in unbundling and upcoding schemes: In this case, a medical services provider inflates medical bills. These bills are inflated by using various billing codes indicating the need for expensive treatment procedures.
In the last few years, the crackdown on Medicare frauds has picked up momentum. Law enforcement agencies are very vigilant to keep a tight grip on scammers. Public awareness on the False Claims Act and several other provisions designed to assist whistleblowers have worked wonders in the last few years.
