Healthcare Fraud: A Safe and Profitable Return on Criminal Investment
By: David S. Barmak, JD, CEO
Healthcare Fraud: A Safe and Profitable Return On Criminal Investment
The Centers for Medicare & Medicaid Services (CMS) estimate that $100 billion of healthcare fraud occurs annually in the United States. This figure is based upon a fraud estimate of 10% of annual Medicare spending ($600 billion) and Medicaid spending ($415 billion). Total healthcare spending for these programs exceeds $2.7 trillion.
On-going healthcare fraud includes, but is not limited to, the following areas:
Upcoding for real services provided;
Billing for non-existent services;
Identify theft used to obtain prescriptions for controlled substances;
Long-term care pharmacies bribing skilled nursing facility employees for leftover medication, then repackaging, providing as if new, and billing Medicare for new medication;
Pharmacies paying Medicare beneficiaries with necessary medication in exchange for medical information that enables the pharmacy to bill Medicare for more expensive medication;
Drug traffickers and physicians teaming up to have healthcare clinics submit false claims to Medicare for medication payments;
Ambulance companies paying patients to pretend that emergency transportation is required because the patients falsely claim that they cannot walk.
I can remember that back in the late 1980’s, Medicare and Medicaid did not efficiently share information – well, that has changed. I remember that about 10 years ago, the New Jersey Fraud Unit hired its first nurse to help integrate fraud enforcement with clinical information. The sheer volume of medical claims today – millions are processed each and every day – supremely challenges law enforcement, in particular Medicare and Medicaid enforcement authorities, to share information and target criminals affecting the greatest volume of claims.
An effective Compliance Program designed to minimize and prevent fraud, waste and abuse, is not only required by law, but also is most effective in persuading enforcement authorities that you are a “good apple” when authorities understandably, but incorrectly, believe all facilities to be together in a bushel basket of “bad apples.” By taking the Compliance Program requirements seriously and ensuring that all staff members are properly trained and follow the rules, a facility can maintain “good apple” standing consistently.
For more information regarding this article, call 609-454-5020 or email info@mednetconcepts.com.
