Medicare Fraud

Healthcare today is one of the most lucrative businesses in America and many people are trying to take advantage of that. One of the reasons in the transition of street crimes is how much safer it is compared to the drug business. If we take a look at South Florida, we can see hundreds of people living the “high life”. The truth is rarely anybody sells drugs and more than half of those people are involved in healthcare, both legally and illegally. A couple of months ago, several onlookers observed a pharmacy down the street. But unlike the conventional pharmacy, there were no customers seen coming in or out.

After about two weeks, the pharmacy closed up and became a warehouse. This became a concern among some of the public because true pharmacies do not fold up without warning. The authorities were notified immediately and this became a sign of Medicare fraud. Medicare is an insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over, or who meet other special requirements. The bill was signed by President Lyndon B. Johnson as an effort to promote cheaper medical care for the elderly.

Fraud is any criminal activity where one uses deceptive action for personal gain or in some cases, damage to another individual. Therefore, Medicare fraud is where people (i. e. the party involved) deceive patients and the government in order to collect reimbursement from Medicare falsely. Medicare fraud involves using others’ information, namely their social security and their Medicare number to obtain money from the government. It is considered a criminal offense, by law, and can be punished severely, usually by a substantial amount of prison time and fines.

Medicare fraud is not a shock to the medical community anymore; it’s becoming more commonplace to steal from the elderly, the disabled, and the handicapped, but the sad thing is that no one is doing anything significant to stop this action. We see these businesses everyday in our community, but give them barely any attention at all. Working alongside the medical community, we can conjure up a solution that is both useful and can suppress this fraudulent activity. Today, Medicare fraud is carried out in every healthcare setting imaginable.

Its whereabouts are seen in hospices, hospitals, minor clinics, dental offices, optometry offices, and even in therapy offices. If one takes a look at South Florida, rehabilitation and mental health centers are also in use for Medicare fraud. If one looks hard enough, it can also be present over the Internet, usually with the indication of large flashy web banners and the promise of “free wheelchairs” or a large sum of money to partner with them. Medicare fraud usually comes in three forms: phantom billing, patient billing, and unbundling.

Phantom billing is where one bills Medicare for unnecessary equipment or procedures. This is very common among parties and their associates. A common example would be a corporation billing Medicare for a colonoscopy on the behalf of a patient when the patient has never had a history of colon problems or has a different condition. Patient billing is a little more direct with respect to the patient. Sometimes, the party involved will bribe homeless individuals with food, money, and a clean place to stay if they cooperate and pretend that they are ill.

During this period of time, the party would have been a step ahead, planning the next phase of the fraud. Depending on the clinical setting, certain methods of advertising will be used to lure easy bait for distraction, so that it will seem that these people are actually running legitimate clinics. For example, one hospital located in New York City had an advertising technique where they would summon the homeless with flyers and forms promising cash and food, but outside the “interview” room, there was a sign with a foreign man putting his finger to lips, indicating silence.

In Russian, the poster translated out to “Silence, even the walls are listening”; they obviously do not want their secret leaking out to anyone that can stop their plans. Sometimes, if they cannot run their business in a large area, these fraudsters get very creative and obtain a list of patients’ names from secure databases and their underlying condition, if any. If it is convenient, the party of fraudsters will send an “EMT technician” or a poser to pick up the patient at his or her house. The patient will then be transported to their facility and given no or unnecessary treatment.

During the patient’s stay at the clinic or hospital, ploys will be devised by the party to make sure the patient is not aware of what is actually occurring. Actors or members of the party will gather around the patients or take a few of them into a room and use techniques that are very unnecessary according to their underlying condition. Afterwards, the patient will be brought back home. Sometime later, the patient will receive a bill for a large sum. This is one of the more common methods of carrying out these types of operations (i. e. patient billing).

The last common method of Medicare fraud is known as unbundling. This involves obtaining a list of items that can be billed at expensive rates. These items billed for usually involve a need for more comfortable living, such as wheelchairs or mobility scooters; they are known as DME or Durable Medical equipment. This all seems very compelling, but to understand further what takes place at these institutions, its legal implications, and the financial problems for the government, it is necessary for us to take and analyze a sample fraudulent case for ourselves.

This case about a certain man named Philip Mejorado. Philip Mejorado wakes up on a Monday morning. He turns on his computer to check on his business account. He finds his balance to be about $500,000 more than it was yesterday. He smiles to his satisfaction, sits back and fires up a quick e-mail to his associate, the one that runs his large medical supplies company in downtown New York. But what we find unique about his company is that there are no supplies at all. In fact, there are no customers either. From the very start, this kind of business can arouse instant suspicion.

Going further into normal business operations, we find that, Philip, through his contacts, has obtained a database full of patients’ names, their underlying conditions, social security numbers, and Medicare information. Philip and his associates send out bills by day to the government (i. e. Medicare) for large, unnecessary amounts of medical equipment that are worth thousands. This is a case of direct unbundling. For example, a certain Mr. John Smith is being billed for 2 mechanical legs, 2 mechanical arms, and a wheelchair, but does not actually need these items.

The bill, however, is sent and the check from the government is received within a week due to a policy that is set by Medicare. Sometimes, due to the suspicious nature of these companies (such that Philip is running), the government sends out agents to the company within 30 days, but by the time they get there, all is gone. Such is the classic example of Medicare fraud. Philip was not a business administrator; he was a con-man who wanted to make money off of the government through fraudulent means.

However, the government has too many obligations and annot monitor every piece of information that goes out in the Unites States to these companies. No one can really tell if they are legitimate companies. But if each bill were processed individually, one can detect mistakes by comparing the items billed for and the patients’ underlying conditions. In this case, the government should have easily detected a flaw in the bill sent by Philip’s associates. The primary mistake they should have caught was the fact that 4 mechanical limbs and an additional wheelchair were being billed to the same patient.

Logic, from here, can intervene and ask: Aren’t these limbs meant for mobility (i. e. movement of the arms and legs). There is no need for an additional wheelchair because it is unnecessary and the patient can already use the limbs to move when received. The government should keep to its policies, but should easily be able to determine billing mistakes with sheer faculty. Philip has now escaped the law and will spend Uncle Sam’s money lavishly like the 3 million people involved in these activities. He will then moves on to his next scheme and take his associates along.

But given that Philip was investigated thoroughly and charged with fraud, the American justice system will not overlook his actions by using loose constructionism, but Philip will have to serve time in jail. Depending on whether the crime was considered civil or criminal, the defendant (i. e. Phillip) must be punished. In a civil case, depending on the severity of the fraud, Philip will not be incarcerated, still has to pay up to three times the damages, is excluded from Medicare benefits, and pay a settlement agreement.

In contrast, a criminal case would earn Philip 5 to 10 years in federal prison, asset seizure or forfeiture, plea agreements, the exclusion from Medicare benefits, and loss of his license (i. e. if he has one). These people are very dangerous and people are getting caught every day. What the medical community want these people to understand is the fact that they are committing a very high crime to society and must face the consequences. Even when Philip comes out of prison and feels that he has learned his lesson not to steal, he is useless to society.

He is and will always be a criminal to society. Government awareness is waning and needs to be revived quickly before these numbers escalate. The government needs to crack down more on corrupt providers that want to steal from the government and taxpayers. When Medicare was able to combat fraudulent cases in South Florida, fraudulent DME claims dropped $1. 76 billion dollars a year. But this still does not solve the large amount of fraudulent parties in healthcare. We need to find quick and sharp solutions that will have a sound impact on the fraudulent cases in the United States.

According to CBS News, the government has planned to develop a piece of software that can monitor the flow of information realtime. Business administrators must have their companies registered within the government and undergo inspections periodically. Even so, certain people are still aware on how to bypass the system. The government should take action by constructing a new IT based project that does not allow “outside” workers to assist in the making of the project. In other words, only government authorized personnel will be able to oversee the progress of the development.

This will probably keep out fraudulent activity because it only allows the government to monitor the changes in the building of the software. Not many people that are fraudulent are allowed to work with the government. I suggest the government should promote very strict codes that will ensure that activity will be monitored. For example, all medical companies and institutions should be registered in an encrypted database that is updated frequently. The database will contain patients’ names, social security, conditions, insurance companies, histories of admission, and billing information.

If any of these pieces of information change drastically, a hotline will be contacted and an investigation will occur as soon as possible. Even so, this may require more government workers to have a greater flow of information and the ability to travel down the food chain more smoothly. More workers can also be substituted for additional investigators of these cases involving Medicare fraud. These investigators will obviously be spread out in local areas waiting for contact and overseeing the management of certain healthcare facilities in the area. Using these solutions can put us back on the road to success in the Medicare sector.

It is great disrepute to our nation that we still have people stealing from Medicare, not only through false billings, but also the abuse that accompanies each patient that is fallen by the trap set by these operators. People are using others’ information, making money and fleeing, looking for a new plan, leaving used patients confused and unhappy. These are con-men that take money out of the U. S. government, but try not to pay the price for their action. Through government awareness, we can catch them and make them pay, severely. That’s the punishment for stealing from Medicare.

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