2011 Medicare Fraud Strike Task Force Charges
In September 2011, a nationwide takedown by Medicare Fraud Strike
Force operations in eight cities resulted in charges against 91
defendants for their alleged participation in Medicare fraud schemes
involving approximately $295 million in false billing.[25]
Defendants convicted of Medicare fraud face stiff penalties according
to the Federal Sentencing Guidelines and disbarment from HHS programs.
The sentence depends on the amount of the fraud. Defendants can expect
to face substantial prison time, deportation (if not a US citizen),
fines, and restitut
Read more: http://www.answers.com/topic/medicare-fraud#ixzz1szHABx5S
Read more: http://www.answers.com/topic/medicare-fraud#ixzz1szGsO8mA
In the United States, Medicare fraud is a general term that refers to
an individual or corporation that seeks to collect Medicare health
care reimbursement under false pretenses. There are many different
types of Medicare fraud, all of which have the same goal: to collect
money from the Medicare program illegitimately.
The total amount of Medicare fraud is difficult to track, because not
all fraud is detected and not all suspicious claims turn out to be
fraudulent. According to the Office of Management and Budget, Medicare
"improper payments" were $47.9 billion in 2010, but some of these
payments later turned out to be valid.[1] The Congressional Budget
Office estimates that total Medicare spending was $528 billion in 2010.
[2]
The Medicare program is a target for fraud because it is based on the
"honor system" of billing. It was originally set-up to help honest
doctors who helped the needy with medical services. There are few
safeguards to eliminate false claims.[citation needed] In fact, claims
are paid automatically because the goal of Medicare is not to root out
false claims, but to pay claims quickly and smoothly.
Contents
1 Types of Medicare fraud
2 Prime Healthcare
3 South Florida
4 Columbia/HCA fraud case
5 Law enforcement and prosecution
6 Medicare Fraud Reporting By Whistleblowers
7 2010 Medicare Fraud Strike Task Force Charges
8 2011 Medicare Fraud Strike Task Force Charges
9 Organized crime
10 See also
11 References
12 External links
Types of Medicare fraud
Medicare fraud is typically seen in the following ways:[3][specify]
1.Phantom Billing: The medical provider bills Medicare for unnecessary
procedures, or procedures that are never performed; for unnecessary
medical tests or tests never performed; for unnecessary equipment; or
equipment that is billed as new but is, in fact, used. In which case,
every form of billing, phantom or patient, can be prevented through
carefully checking.
2.Patient Billing: A patient who is in on the scam provides his or her
Medicare number in exchange for kickbacks. The provider bills Medicare
for any reason and the patient is told to admit that he or she indeed
received the medical treatment.
3.Upcoding scheme and unbundling: Inflating bills by using a billing
code that indicates the patient needs expensive procedures.
A 2011 crackdown on fraud charged "111 defendants in nine cities,
including doctors, nurses, health care company owners and executives"
of fraud schemes involving "various medical treatments and services
such as home health care, physical and occupational therapy, nerve
conduction tests and durable medical equipment."[4]
In recent years, as regulatory requirements tightened[5] and law
enforcement has stepped up, Medicare fraud has shifted away from
sectors such as durable medical equipment[6] and HIV/AIDS infusion
injections and into other areas such as ambulance fraud and hospice
care fraud.[7][8] Durable medical equipment or home medical equipment
describes medically required equipment and services used in the home
such as wheelchairs, hospital beds, nebulizers, and oxygen equipment,
and represents less than two percent of total Medicare spending.[9]
Even in other countries, particularly in South-East Asia, there are
doctors who over-charge American patients, through Medicare (or
Tricare), charging them US rates, much higher than actual medical cost
in their respective countries. This is a type of insurance fraud,
which, unfortunately, Medicare continually overlooks and fails to take
into account.[citation needed]
Prime Healthcare
Prime Healthcare Services is under investigation by the United States
Department of Health and Human Services and the California Department
of Justice about concerns over a reported spike in septicemia. The
investigation centers around whether the spike in septicemia
represents a large public health issue or multimillion-dollar Medicare
fraud. Six Prime hospitals ranked in the 99th percentile of U.S.
hospitals for septicemia and five were in the 95th percentile.[10]
There is also evidence that Prime Healthcare Service engages in
upcoding elderly patients to malnutrition. In Mount Shasta,
Victorville and in the Mojave Desert, Prime has had high rates of
kwashiorkor amongst its elderly patients. At Shasta Regional Medical
Center, Prime reported 16.1% of their Medicare patients suffered from
kwashiorkor. The state of California average for Medicare patients is
0.2% suffering from kwashiorkor.[11]
Prime also has come under scrutiny by investigators over expenses on
luxury items disallowed by Medicare. Authorities have flagged $491,000
in operating costs in relation to a Eurocopter for the Chief Executive
Officer, Lex Reddy. The Department of Health Care Services also
identified and disallowed $820,000 for the lease and taxes on a home
in Beverly Hills and $303,000 in depreciation on the Helicopter and a
Bentley. The funds flagged by auditors do not represent tax dollars
that have been sent to Prime. Rather, they signify sums that the state
will not recognize when compensating the chain for its corporate
office expenses.[11]
Prime maintains that their billing practices are legal and proper and
claim that the high rate of kwashiorkor is a result of proper
diagnosis of malnutrition. They also claim that they are the victim of
a campaign by SEIU, but the California Medi-Cal fraud director has
stated that his bureau had initiated an investigation before SEIU
released their findings.[11]
South Florida
Map of Florida highlighting South Florida.The South Florida area has
become the epicenter of Medicare fraud in the United States. In 2008,
criminals from two Florida counties alone accounted for approximately
$400 million in fraudulent Medicare bills.[citation needed] Also in
2008, Miami-Dade County billed Medicare six times more for home health
services than Los Angeles County, where the Medicare population is
three times larger.[citation needed] In fact, the problem has become
so rampant that in 2008, federal investigators found nearly half of
all DME suppliers in South Florida were not in compliance with
Medicare rules. In response, the authorities required every single
medical equipment supplier to re-apply for billing privileges.[12]
In 2005, 72% of all Medicare claims nationwide for HIV/AIDS infusion
injections were billed in Miami-Dade County.[citation needed] Many
recent immigrants to South Florida open up a company and immediately
start billing Medicare for tens of thousands in equipment and services
that Medicare beneficiaries never receive.[citation needed]
Many South Florida drug dealers look to Medicare fraud as the new
crime of choice. Criminals, now federal defendants, report that (1)
there is more money in Medicare fraud than in drug smuggling, (2)
there is a lesser chance of being caught and, (3) if caught,
defendants are treated like a white collar criminal as opposed to a
drug dealer.[citation needed]
Columbia/HCA fraud case
The Columbia/HCA fraud case is one of the largest examples of Medicare
fraud in U.S. history. Numerous New York Times stories, beginning in
1996, began scrutinizing Columbia/HCA's business and Medicare billing
practices. These culminated in the company being raided by Federal
agents searching for documents and eventually the ousting of the
corporation's CEO, Rick Scott, by the board of directors.[13] Among
the crimes uncovered were doctors being offered financial incentives
to bring in patients, falsifying diagnostic codes to increase
reimbursements from Medicare and other government programs, and
billing the government for unnecessary lab tests,[14] though Scott
personally was never charged with any wrongdoing. HCA wound up
pleading guilty to more than a dozen criminal and civil charges and
paying fines totaling $1.7 billion. In 1999, Columbia/HCA changed its
name back to HCA, Inc.
In 2001, HCA reached a plea agreement with the U.S. government that
avoided criminal charges against the company and included $95 million
in fines.[15] In late 2002, HCA agreed to pay the U.S. government $631
million, plus interest, and pay $17.5 million to state Medicaid
agencies, in addition to $250 million paid up to that point to resolve
outstanding Medicare expense claims.[16] In all, civil law suits cost
HCA more than $1.7 billion to settle, including more than $500 million
paid in 2003 to two whistleblowers.[15]
Law enforcement and prosecution
Cont'd
http://www.answers.com/topic/medicare-fraud
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