Medicare and Medicaid fraud remain a huge problem nationwide. It is an issue that affects all taxpayers, as it essentially represents outright theft of the state and federal governments that we all fund. The fraud take on many forms but, in general, involves cases where providers bill the government for medical care that was not provided, was not necessary, or was not done adequately. This fraud results in tens of billions of dollars being drained from public coffers.
Unfortunately, the problem is notoriously difficult to detect, because it is usually perpetrated by individual doctors, administrators, and other health service providers in positions of trust. There are not nearly enough resources to provide sufficient outside audits to identify the problem. And even then, there are ways to cover up the fraud even from investigators.
For these reasons, most Medicare and Medicaid fraud only comes to light with those with inside knowledge come forward and explain what is going on. In fact, the law has built in incentives to encourage this conduct, providing whistleblowers with a portion of any funds recovered as a result of their stepping forward.
New Allies in the Fight
The Bulletin recently pointed to a new project that seeks to enlist seniors in the fight against fraudulent billing. The idea is to use “Senior Medicare Patrol” teams to train the elderly in ways to spot potentially problematic medical billing which may be a sign of fraud. The volunteers are meant to “serve as the country’s first line of defense when it comes to protection the Medicare and Medicaid programs from waste and fraud.”
In a recent U.S. Office of the Inspector General report on the program, over the last seventeen years, these senior volunteers have identified millions in improper billings.
Essentially, the main focus of the training is to encourage seniors to ask questions and be critical when reviewing their medical bills and insurance information. Far too often, seniors are simply confused by the detailed billings, ignoring any areas of confusion. Those willing to commit fraud actually rely on the complexity of the billing and the unfamiliarity of the patient to get away with unnecessary billing.
A supervisor with one senior patrol group explained “that most of the calls that come through his office deal with situations where a person living in a long-term care facility mistakenly gets billed for their prescription drugs plus another resident’s drugs when the facility processes its drugs at the end of the billing cycle..”
Prescription drug billing are notoriously difficult to track. Not all of these problems necessarily implicate outright fraud–they could simply be administrative errors. Yet, the value of identifying the problem is the same, ensuring that public funds are not spent unnecessarily.
Improper billing affects us all. If you or someone you know may have information about illegal billing practices in a nursing home, hospital, or other service facility, please get in touch with an attorney to see how you can put an end to the practice and take advantage of whistleblower laws.
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