No doubt you have heard about the massive amount of fraud in the Medicare program. Is it true? How do you know who or what to believe? Nancy Healey brings us a few facts to add to the discussion this week.
The Centers for Medicare & Medicaid Services( CMS) is the Federal agency within Health and Human Services (HHS) that administers the Medicare and Medicaid Programs. Their Home Page contains some good information about Medicare fraud. According to CMS, Medicare fraud typically includes any of the following:
- Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain a Federal health care payment for which no entitlement would otherwise exist
- Knowingly soliciting, receiving, offering, or paying remuneration (Kickbacks, bribes, or rebates) to induce or reward referrals or items or services reimbursed by Federal health care programs
- Making prohibited referrals for certain designated health services
Examples of Medicare fraud include:
- Knowingly billing for services at a level of complexity higher than services actually provided or documented in the medical records
- Knowingly billing for services not furnished, supplies not provided or both, including falsifying records to show delivery of such items
- Knowingly ordering medically unnecessary items or services for patients
- Paying for referrals of Federal health care program beneficiaries
- Billing Mediare for appointments patients fail to keep
Who commits Medicare fraud?
Anyone who touches a claim can include fake charges. There is a substantial group of perpetrators, including unscrupulous medical providers, healthcare facilities, contracted billing services and even patients themselves, although fraud committed by patients is a small portion of the concern.
CMS says that most physicians work ethically, provide high-quality patient medical care, and submit proper claims. Trust is the core to the physician-patient relationship. Medicare places enormous trust in physicians and relies on their medical judgment to treat patients with appropriate medically necessary services and submit accurate claims.
Unfortunately, Medicare fraud in the U.S. is actually a big deal. The National Health Care Anti-Fraud Association reports that taxpayers are losing more than $100 billion a year to Medicare and Medicaid fraud. The Senior Medicare Patrol estimates this at $60 billion. The amount lost to fraud should not be surprising, considering the total spending on Medicare and Medicaid exceeded $1.6 trillion in 2021 and continues to grow.
The Government Accounting Office recognizes Medicare fraud as a problem. An April 2023 report from the GAO designates Medicare as a high-risk program due to its size, complexity, effect on the federal budget and healthcare sector, and susceptibility to mismanagement and improper payments. GAO says the very complex Medicare program has more than 1.4 million providers and more 20 different payment systems.
Defrauding the Federal Government by committing Medicare fraud is, of course, illegal. It exposes the individuals or entities to potential criminal civil, and administrative liability and may lead to imprisonment, fines, and penalties. Providers and health care organizations involved in health care fraud risk being excluded from participating in all Federal health care programs and losing their professional licenses.
United Healthcare provides 6 tips to help you avoid Medicare fraud, although United Healthcare itself is under investigation for fraud.
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- Keep your Medicare card close and always protect it like your Social Security card.
- Never give your Medicare number to anyone except your Medicare provider or authorized agent.
- Watch out for bogus Medicare plans, products, benefits and services. Their aim is to get your Medicare number. Use the Plan Finder at Medicare.gov to verify any plan you’re considering.
- Do not share your Medicare number in exchange for “free” health care services or products. If they are free, they do not need your number.
- Do not accept medical supplies or information from door-to-door salespeople. Medicare/Medicaid never sends representatives to homes to sell anything.
- Always scour every Medicare statement. Medicare or your private insurer sends you claims summary statements detailing the health care you have received. Verify that you received all the services listed. Report anything you think is in error.
The first thing to do when you suspect fraud is to check with your Medicare plan provider. It may be a simple mistake or misunderstanding. If it still appears that a charge is for a service or supply you did not receive, you should call the Medicare helpline at 1-800-MEDICARE or 1-800-633-4227, 24 hours a day, 7 days a week. You can also call the Senior Medicare Patrol (SMP) office in your state. Their volunteers and staff can help you determine whether there has been fraud and report it to government investigators.
Stolen Medicare numbers are valuable for criminals who use them to bill Medicare for services and supplies never provided or received. The claim reimbursements are pocketed by the criminals. The more paid out in false claims, the less there may be to pay for legitimate health care needs. The long-term results can be higher premiums and stricter rules around eligibility for services and products.
We all pay for Medicare fraud, but we can all help curtail it by regularly reviewing our claims summaries and reporting suspected incidents of fraud.