"Healthcare Fraud Runs Rampant Across the Nation" by Matthew Scarcella

For years, unethical physicians and healthcare facilities have been bilking the federal government’s healthcare programs out of billions of dollars.  According to the Federal Bureau of Investigation, there are at least eight different types of Health Care Fraud that are constantly committed.  The schemes range from “Billing for Services not Rendered” to “Upcoding of Services” and more.  Billing for Services not Rendered, or charging for procedures not performed, is the primary fraudulent issue. Over the years, these tactics have become more complex and therefore it is more difficult to intercept them early enough to halt them in their tracks.  However, progress is slowly being made and more swindlers are finding themselves behind bars.

Currently, there are countless physician offices that continue to process information with paper charts.  With these systems, minimal information is documented.  For example: the diagnosis may simply be referred to as “cough,” and the subsequent plan of treatment will simply say “Benadryl.”  The Center for Medicare & Medicaid Services, CMS, is currently implementing a new regime in which all physician or healthcare practitioners (which includes hospitals, doctor’s offices, home healthcare services, etc.) must be using electronic medical records, or EMRs.   The EMRs are formatted so that doctors must comply and target each individual item on the prepopulated text.  With this compliance, it is far easier to assess what the doctor is doing for the services he is charging for.  This is one way in which CMS is following up on healthcare fraud.  Adhering to these basic standards, chart review is performed, where both Medicare and insurance companies review a group of facilities’ notes and charts, to see exactly what was done and compare it to what was billed.  This procedure helps to eliminate Upcoding of Services. 

One such case of fraud involves an incident earlier in 2012, centered in the Brighton Beach neighborhood of Brooklyn, NY.  In this case, ten doctors took advantage of no-fault claims in nine different clinics across three boroughs of NY.  According to court pages looked over by The New York Times, “the ring sought reimbursement from so many excessive and unnecessary medical treatments that it had set up three separate billing processing companies just to handle the paperwork.”  Even though they were caught, that specific scheme is as elaborate as they come.  Also, this particular scheme was called “the largest single no-fault insurance fraud case in the nation’s history” by Preet Bharara, the United States attorney in Manhattan.  Brighton Beach is unfortunately a notorious area for healthcare fraud.

A more intriguing case, and one that was actually caught on tape, is one that involves Medicare fraud from McAllen, Texas.  In this astonishing case, an 82-year old woman went undercover and was recorded having a conversation with a doctor.  In the video, the woman clearly states that she is in perfect health and has never had any problems.  However, the next day a nurse came to her house in order to treat her for diabetes and other problems that she was supposedly diagnosed with.  According to ABC News, “the overall diagnosis of the undercover grandmother’s health could have provided the justification for what could be tens of thousand dollars a year worth of unneeded treatment and medical supplies and equipment.”  This is only one incident of many and when you look at all the possible ways of committing fraud, you can see how billions of dollars come into play.

The rate at which healthcare fraud has been increasing in the nation is stunning.  No matter how diligently authorities crack down on fraudulent scams, there will always be a new one around the corner.  However, based on information from the United States Department of Health & Human Services, on April 4th, 2012, we can see that there is some hope.  On this day, the Obama administration announced that “in 2011, HHS revoked 4,850 Medicaid providers and suppliers and deactivated 56,733 Medicare providers and suppliers as it took steps to close vulnerabilities in Medicare.”  This is definitely a step in the right direction and the Obama administration is slowly making progress in these traumatic times. 

Works Cited

Chuchmach, Megan.  "Exclusive: Undercover Grandma Catches Medicare Fraud on Tape."  ABC News.  1 Mar. 2012.  Web.  30 Oct. 2012.  <http://abcnews.go.com/Blotter/undercover-82-year-grandma-catches-medicare-fraud-tape/story?id=15818462#.UJCQO_7ANeC>.

Rashbaum, William K.  "A $250 Million Fraud Scheme Finds a Path to Brighton Beach."  The New York Times.  Ed. Jill Abramson.  29 Feb. 2012.  Web.  30 Oct. 2012.  <http://www.nytimes.com/2012/03/01/nyregion/dozens-said-to-be-arrested-in-health-care-fraud-scheme.html?pagewanted=1&tntemail0=y&_r=1&emc=tnt>.

United States.  Dept. of Health & Human Services.  HHS, Department of Justice highlight Obama administration efforts, Health Reform tools to combat Medicare fraud.  4 Apr. 2012.  Web.  30 Oct. 2012.  <www.hhs.gov/news/press/2012pres/04/20120404a.html>.

United States.  Federal Bureau of Investigation.  Financial Crimes Report 2010-2011.  2011.  Web.  30 Oct. 2012.  <www.fbi.gov/stats-services/publications/financial-crimes-report-2010-2011/financial-crimes-report-2010-2011#Health>.

Increasing Premiums and Medicare Fraud? Oh My!

Both candidates mentioned plenty of outstanding sums and fees during the Presidential Debate last week.  Seeing as how all of these numbers being thrown around are terribly confusing, Jen Christensen puts a number of issues into perspective over at CNN.

Evidently, even though health care recipients are paying more in co-pays, deductibles and other various billing issues, which have been steadily increasing since 2001, the majority of the problem is due to the increase in cost of health care and is not actually due to the current President or even the previous one.  Who would have thought?  Technology is advancing and the cost to process tests and order scans is subsequently increasing, and by a very large percentage at that.  Of course, even though the medicinal field keeps undergoing new scientific discoveries that are being incorporated into new methods of diagnosing patient conditions and furthermore treating said conditions, people just take it for granted that their insurance premiums will not go up.

One of the issues that Obama brought up, which Christensen so thoughtfully mentioned, was the fact that Medicare and Medicaid fraud eat up an enormous portion of the budget and that more should be done to stop it.  Looking deeper into the issue over at The New York Times, we can actually see that more is finally being done.  "Ninety-one people including doctors, nurses and other medical professionals were charged criminally after an investigation of Medicare fraud that involved $430 million in false billing in seven cities, officials said on Thursday."  This astonishing find happened just last week.  Reading further, it becomes apparent that another such incident occurred earlier in the year.  With everyone so casually taking advantage of the system, the charges on Medicare and Medicaid are practically compounded, adding up to billions.

Hopefully these busts continue and perhaps if they do and fraud becomes less easy to commit, Medicare may be able to decrease its costs in the coming years.

Unintended Consequences?

Promoted by the Bush and Obama administrations as a cost-cutting measure, have electronic patient records actually led to increased healthcare costs?

According to an analysis by the New York Times, the push to streamline patient record keeping through federal subsidies for electronic records systems may end up increasing costs to Medicare.  The federal government has provided billions of dollars to hospitals to upgrade to the new electronic systems, in hopes of "improv[ing] efficiency and patient safety", in addition to reducing healthcare costs due to misdiagnosis and duplicate medical tests.

However, several doctors and healthcare experts interviewed by the Times say that the new systems make it easier for hospitals to "upcode", an industry term for defrauding Medicare by using medical codes for care that was never received by the patient.

The Times article quotes a Health and Human Services Department spokesperson stating that Medicare "has strong protections in place to prevent fraud."

Update:  The federal government has responded to the original story, sending a stern letter to hospitals discouraging the "gaming" of the system described above.