It’s a staggering number. According to the federal Government Accountability Office, Medicare paid almost $60 BILLION in fraudulent payments in just 2014 alone!!!! So, to get a full understanding of this sickening fact, let’s look at the “who, what, when, why and how”…
Who is responsible for the fraud? Providers of medical services are. Doctors, medical imaging companies, home health care group and individuals involved in elaborate schemes where they act as doctors to receive payment or individuals finding social security numbers and selling them to organized crime rings.
What constitutes the fraud? Billing Medicare for services never given to an individual, billing Medicare for unnecessary services, and Billing Medicare for services given to someone who doesn’t “exist”.
When will this end? The Affordable Care Act started the ball rolling. A lot of billing is now reviewed first prior to payments being made on claims. Site visits to high volume billing providers uncover false storefronts and payments are never made due to these findings. Insurance companies are sharing data with the government to help identify vulnerabilities and providers of concern.
Why is Medicare fraud hard to stop? 4.5 million claims a day come into Medicare and more than $1 billion in payments are made daily. That type of volume makes for extreme challenges especially in an open system like Medicare. Unlike Medicare Advantage plans that utilize networks which remove the risk of fraudulent billing, Original Medicare is required by law to allow providers that meet a base set of requirements to bill for services they give to Medicare beneficiaries.
How can you help? If you are on Original Medicare (Medicare Advantage members don’t need to worry about Medicare Fraud) inspect your Medicare explanation of benefits and bills. Make sure the services billed were received. If you suspect fraud, call Medicare’s hotline: 800-447-8477.