For most people, conducting life’s daily affairs with honesty and integrity is just a matter of course. But for a small criminal-minded sub-section of society, any unattended area of daily life is ripe for making a quick and illegal profit. Such is the case with the growing problem of Medicare fraud in the United States today. Health care reforms are certain to have a financial impact on both patients and providers, and while most individuals and professionals seem set to navigate the reforms in the best way they can, for some, these reforms and the confusion they are causing are just another opportunity to commit fraud. Because of this, the U.S. Department of Health and Human Services has now issued a booklet called “Protecting Medicare and You from Fraud” to help you learn how common Medicare fraud really is and what you can do to protect yourself and your loved ones.
Medicare Fraud Defined
The U.S. Department of Health and Human Services defines Medicare fraud as what happens when “Medicare is billed for supplies or services that you never got.” The impact of ongoing Medicare fraud boils down to continual increases in the cost of health care and higher taxes. While many cases of Medicare fraud are subtle and small — designed to fly under the radar — other cases are ongoing and sensational. The recent conviction of New Jersey cardiologist Dr. Jose Katz is a perfect example of how serious Medicare fraud can become. In what is now being called the largest single case of sole provider Medicare fraud in the tri-state area (New York, New Jersey, Connecticut), Dr. Katz was recently convicted of multiple counts of Medicare, Medicaid and insurer fraud. During the period the fraud was occurring, Dr. Katz bilked insurers out of more than $19 million.
Types of Medicare Fraud
There are several different ways that Medicare fraud can occur. As such, students who are planning to graduate with their online masters degree in public health may find this is a rewarding field in which to build a career. Medicare fraud counts on the honesty of patients in trusting that their bills are accurate, their procedures are necessary and their health care providers are trustworthy. These are some of the
most common Medicare fraud schemes happening today.
- Identity theft. This is not just an issue found in Medicare fraud, but Medicare fraud can be one outcome of becoming a victim of identity theft.
- Unnecessary procedures. This is where a patient is given tests or procedures they do not need. The case against Dr. Katz included multiple counts of unnecessary procedures.
- Phantom billing. This technique is as it sounds: The physician’s office submits a bill to Medicare for patient services that were never rendered.
- Generic drug substitutions. Medicare fraud can be committed when Medicare is billed for brand-name medications when generic medications were given to the patient.
- Upcoding. Upcoding occurs when a doctor orders a certain procedure for a patient but then codes the bill for a more expensive procedure than what was performed.
- Equipment substitution. Similar to upcoding, equipment substitution happens when Medicare is billed for expensive or new equipment but that is not provided to the patient.
How to Protect Yourself
Protecting yourself from Medicare fraud begins and ends with becoming your own patient advocate. This means checking and double-checking your bill before you pay it, asking all the questions that you have before accepting the charges and disputing any bills you do not recognize or agree with. You must also be vigilant about getting a second opinion for all tests or procedures ordered if you feel the slightest doubt. Medicare fraud is much less likely to occur when you are “on the job” working for yourself and vulnerable loved ones to ensure your medical charges are both accurate and necessary.
How the Government Is Protecting You
The federal government has taken several recent steps to crack down on Medicare fraud. With a new team called HEAT (Health Care Fraud Prevention and Enforcement Action), ramping up sentencing and penalties for convicted Medicare felons, the formation of Senior Medicare Patrols and installation of new fraud detection technology, it is clear that the real fight against Medicare fraud is just getting started.
About the Author: Matthew Benjamin comes from a long line of physicians. He is currently set to graduate this spring with a degree in public health. He hopes to work in the field of health care policy and insurance education.
How Common Is Medicare Fraud?