The Changing Face of Health Care Fraud

Tom aka Rusty Rustbelt

The Changing Face of Health Care Fraud

Every President since Gerald Ford has campaigned against Medicare and Medicaid โ€œwaste, fraud and abuse.โ€ Ditto many people campaigning for Congress.

The primary fraud prevention systems are aimed at providers, with the Office of Inspector General (DHHS โ€“ CMS) and the FBI taking the lead on large fraud cases. States are also very active in Medicaid fraud investigations. Providers spend vast sums every year to prevent fraud, usually in the form of compliance plan activity.

The leading presumption is fraud will be perpetrated by providers via double billing, upcoding, kickbacks, and etc., but the face of health care fraud is changing.

Exact numbers are hard to find, but by monitoring several sources it appears non-providers (some mobbed up and some immigrant groups) are combining ID theft and computer driven fraud to suck funds out of Medicare and Medicaid.

60 Minutes did a program recently on phony pharmacies and DME* shops in Miami, and one informant guessed there may be 2000 phony shops in the Miami area alone. Wow.

The key is to do a real credentialing process before issuing a provider ID number. Physicians jump many hurdles to get a number, despite piles of credentialing paperwork, but apparently phony suppliers can begin billing almost immediately.

The feds are still aiming at legitimate providers with the Revenue Audit Contractor (RAC) program. Likely the contractors will find some billing errors at every single provider, sweeping up crumbs while real criminals are abusing the treasury.

*Durable Medical Equipment
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Tom aka Rusty Rustbelt