health Insurance Article

5 Medicaid and Medicare Fraud Everyone Pays For

As of 2008, more than 44 million people were enrolled in Medicare, and close to 40 million people were participating in Medicaid. With the recent move to expand Medicaid, many more people will be given access to the program, but unfortunately that means the number of Medicaid and Medicare scammers will also grow. Due to the nature of these programs, the criminals who attempt to scam and defraud people can come in many forms — sometimes even in the form of those we usually greatly trust and would least suspect. Doctors, nurses, and insurance agents are some of the most common perpetrators, oddly enough being the ones who regularly have to watch out for fraud. They know how to spot it, but for the average Joe, it can be hard to spot Medicaid and Medicare fraud. However, it’s possible if you know exactly what to look for. Here are some of the most common forms of Medicare and Medicaid fraud to be on the lookout for. Medicaid-Fraud-and-Abuse

1. Payable to Dr. John Smith, for Services (Never) Rendered

When you visit the doctor, you have to provide a Medicaid or Medicare card. The doctor then uses that card to file a claim with the government. The government will review the claim and then pay the doctor for the services provided. Do you think medical expenses are high? Of course you do — so do doctors. That’s exactly why some doctors file several claims for services you never even thought of getting. Although doctors may not look like our commonly preconceived notions of criminals, it’s still fraud they’re committing when they add extra charges here and there after your visit. All sorts of doctors get in on this “oldie but goodie” fraudulent tactic too. One dentist thought he could get away with filing 991 claims in one day. Needless to say, the scammer was caught. He must be really, really great at his job, because that number of claims makes it sound like people just can’t wait to go to the dentist and are going every chance they get.

2. For Rent: My Medicare/Medicaid Number

Yes, that’s right — there are people renting out their own Medicare and Medicaid numbers. In this particular scam, both the beneficiary and health care providers can be criminals. For some, it sounds like a nice arrangement to give someone these numbers so multiple individuals can file claims and pay the “landlords” a hefty cash sum in exchange, sometimes up to 50%. Some rent out their policy number to providers, who will bill through that policyholder’s number for services never rendered. In turn, the doctor will write a prescription, er, check to the eager patient. The most common “landlord/tenant” scam though happens when a health care provider rents out their provider number, making claims through several beneficiaries’ numbers and pocketing the reimbursements. Sometimes, other health care providers even “rent” another doctor’s provider number too if they don’t have their own. A new criminal spin on the classic “student fakes being sick to go to the doctor in order to get a doctor’s excuse for skipping school” trick, the Medicare/Medicaid recipient doesn’t even have to go to the length of pretending to be ill, and doctors don’t have to beg for spare change anymore. Instead, the recipient just provides their number and sits back while doctors and other co-conspirators make phony claims that they’ll all split. This can go on for years too. A 71-year-old licensed professional counselor in North Carolina, Linda Radeker, thought she’d hit it big over the course of three years from 2008 to 2011 when making false insurance claims for services she’d never provided. But when you steal $6.1 million from the federal government, someone will notice. I wonder if they require a security deposit or advertise on Craigslist…

3. Equipment Malfunction: Medical Equipment Scams

For some people, things like wheelchairs, oxygen tanks and walkers are a necessity to everyday life, but for others, they merely look like dollar signs. Medicare spent more than $10 billion on durable medical equipment in 2009, and almost half of that money went to unnecessary equipment or wrong billing. If a doctor offers you a free wheelchair or a company insists you use only their doctors, it’s possible they have a bigger plan. Some doctors even bill patients for prosthetic limbs they never even needed, giving phantom pain a whole new meaning.

4. Team Players: Multi-Company Personal Kickbacks

This type of scam is more complicated, requiring participation from many different individuals and organizations. Think of it as the Medicaid/Medicare Mafia, except most of them are wearing white coats. Some medical professionals realize they can all bill Medicaid or Medicare for multiple types of services when working together and then split a big jackpot. This has become so popular and lucrative that many types of criminals previously associated with more “dirty work” have gotten into the health care business, proving that organized crime needs to be just that when stealing from the government. I seriously doubt this is something they hear about during a motivational teamwork speech at a TED conference.

5. Double the Billing, Double the Fraud

When you get two bills in the mail from your doctor, you notice. You pick up the phone immediately and let every single automated voice know exactly what’s happened. However, when the government gets two bills, already swimming in a pile of mail, they often forget ever paying the first one. So what happens? The second bill gets paid. Scammers know this and depend on the government’s financial responsibility. Many doctors’ offices and practitioners will bill private insurance companies as well as government programs, or two providers will request the same payment. One prominent New York hospital was caught doing just this, and was ordered to pay back more than $2 million to Medicare and Medicaid. As far as I know, there’s not any kind of “two-for-one” deals at a doctor’s office, but apparently some doctors think otherwise.

So What’s the Big Deal?

It’s not our problem though, right? And it’s the government’s deep pockets these people are stealing from, right? It may seem harmless to skim a little bit off the top then. The fact of the matter though is that when Medicaid and Medicare are defrauded, it creates a ripple effect hitting everyone hard. There are estimates that Medicare fraud alone cost American taxpayers anywhere from $50-$90 billion annually, with Medicaid’s fraudulent amount creeping closely behind. So it’s not just the government’s pocket being pick-pocketed — it’s yours too. Ultimately, this drives up the cost of health care for everyone, whether you have government-sponsored insurance or not.

Luckily, actions are being put into place to crack down on scammers. While it’s not cheap to hunt the criminals, the government gained more than $1.85 billion in 2010, which, when compared with 2004’s $573 million, is much better. But there are steps you can take to protect yourself, and these two rules are ones that are easy to practice and can usually help catch almost any kind of fraud quickly:

  • Don’t give personal information over the phone. Many scammers prey on the elderly or very trustworthy, prompting such victims to believe it’s a government official they’re giving their health program numbers to. The same rules that apply to your Amazon.com account apply to these situations too — no real official will ask for such personal information over the phone, via email, or (although you’d think the line would be drawn somewhere) on a social media site.
  • Review your bills and statements. Make sure everything on your statement is something you’ve actually received. If it doesn’t look right, start digging for answers. Ask health care providers for more information, and keep a list of all services and procedures you have done. If you care for an elderly family member or friend, or a child on Medicaid, keep this record for them.

Identifying scammers requires a team effort just like committing the crime does. Taking an active role in your health care will not only give you more control over your health, but it may help prevent crime at the same time. Any kind of insurance fraud is a terrible crime that leaves the rest of us paying for it, but Medicare and Medicaid fraud is especially unfortunate because those who are often preyed upon are some of the most vulnerable people in the country.

Follow Desiree on Twitter @DesireeBaughman.

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