Medicare Fraud

How Whistleblowers Help the Government by Reporting Medicare Fraud

Medicare Fraud and Medical Billing Fraud

Medicare fraud is big business and costs the government billions of dollars each and every year. The government considers it a high risk program that is in some need of reform. This is due in part to its vulnerability to fraud as fewer than 5% of Medicare claims are audited and because of the long term financial problems that the program has.

Medicare covers a person in four main areas and they are:

    Medicare Fraud
  1. hospital insurance
  2. prescription drugs
  3. medical insurance
  4. Medicare advantage plans

These are the benefits that a person can receive when they qualify for Medicare but are of course subject to necessity, and fraud can occur in any of these areas.

Examples of Medicare Fraud

When it comes to Medicare fraud cases, it's not as if they are few and far between. The statistics are shocking and it’s the American taxpayers who suffer. Here are some examples of Medicare fraud:

  • According to the US Office of Management and Budget, in 2007 (one of Medicare's worst hit years for scams) they paid out around $23.7 billion in fraudulent payments.

  • Another surprising statistic is that between the years 2000-2007 Medicare also shelled out payments totaling $92 million spread amongst 478,500 claims for the services of physicians who had either simply never existed or had long been dead when the claims were processed.

  • In 2006, around twenty nine percent of claims paid out by Medicare for durable medical equipment were fraudulent. This is nearly one in three.

  • According to the American College of Radiology after an investigation in 2004, Medicare paid out over $16 billion for imaging tests that were ordered by doctors that were simply not necessary.

  • And finally just when you think that it cannot get any worse, let's take a look at Medical billing fraud. Between the years of 2001 and 2006 Medicare paid out more than $1 billion in highly questionable claims for medical supplies that upon investigation, patients didn't really need. These included walkers for patients with reported sinus infections or shoulder injuries. Also hundreds of thousands of claims were made for glucose test strips that are meant to test for diabetes levels; however it was found that the people claiming for them had everything from breathing problems to migraines and even sexual dysfunction.

Reporting Medicare Fraud

Clearly this is a problem that affects every US citizen, because while the government has to bolster funding for Medicare, it is the American taxpayer who will be expected to make up the shortfall. This also means that funding won’t be in place for other important legislation which could help people. Therefore the government has developed an incentivized reporting program which gives anybody the right to bring a claim on behalf of the government and in return if the case is successful, they should receive a percentage of the amount that has been defrauded.

There are some stipulations you should understand about whistle blowing:

  • The amount defrauded should be above $1 million, and above $2 million in some states
  • The fraud cannot already be public knowledge
  • The plaintiff cannot have planned the fraud

When you consider that the rewards for successfully reporting a fraud case can be somewhere between 10% and 30%, the reward could be quite a lot of money. Whistleblowing is now often looked upon as heroic and 'doing the right thing'. So with this in mind how do you spot and report Medicare fraud?

Medicare Billing Fraud

If you work at a doctor’s office or hospital and you thing that your organization is knowingly over-billing the government, you should contact an employment attorney. The reason for this is that Medicare billing fraud is one of the most common ways to scam the system. This can include billing for services never provided or for patients who never existed. It can also involve deliberately recommending treatments which are not necessary.

It can be confusing and scary to be an employee who thinks that medicare fraud may be occurring at your place work. The good news is that you don’t have to go it alone. You should call an experienced employment attorney who can help you navigate through these complicated laws. At the Law Offices of David H. Greenberg we have attorneys you can speak to for free. Call us at 1-888-204-1014 for a free consultation.

The bottom line is that something has to be done regarding Medicare fraud. If scammers and fraudsters know that not only are they going to have to keep a watch out for the government, but also any member of the public, they may well think twice before committing the crime.

Stopping Medicare Fraud

Clearly trying to stop Medicare fraud is like trying to stem the tides. It's gotten so out of control that the government seems powerless to stop it. Medicare is facing some serious challenges ahead and some people say that if the system keeps on being abused, then it will run out of money by 2017.

Here is an example of why Medicare is in trouble:

If you take an average couple, then in 2010 (according to the Associated Press) their joint household income would be somewhere around $89,000. If they retired in 2011 and were eligible for Medicare then they should have already paid in around $114,000 in Medicare taxes. However because people are living far longer now than the estimated age back in 1965, then their expected medical treatment costs including prescriptions are projected to be around $355,000.

As you can see, that's a short fall of close to a quarter of a million dollars. Add to this the fraud aspect and it doesn't take a genius to work out that the Medicare program is seriously draining the government coffers.

A History of Medicare Fraud

Medicare first came into being in 1965 when the then President, Lyndon B. Johnson, created the act as an attachment to existing social security legislation. In essence it is a social security program that provides health care insurance cover to persons aged 65 or over or for those who are under the age of 65 but who have a physical disability or are disabled, or to those who meet other specialized criteria.

Medicare Fraud Articles