Medicare and Fraud

Medicare admits that fraud has exceeded $60 billion annually. This is why Medicare is taking up so much of the federal budget. Eliminate the fraud and the government can use that money to do other things.
I personally believe that much of the fraud could be eliminated if CMS put some controls in place to prevent fraud, waste, and abuse.
CMS processed millions of claims daily so one would think that putting some controls in place would certainly help? Believe it’s really very simple to eliminate some of the fraud. CMS uses a mainframe to process those claims. All they would have to do is have a report writer available to sort the claims by Hospital, Doctor, and other practitioners by day and by procedure. That will develop a pattern that should assist in identifying those Hospitals or Doctors committing the fraud.
Let’s use a simple example: When sorting by Doctor, by day and by procedure you develop a pattern. Doctor Office Visits are divided into categories; initial exam (new patient), basic exam, intermediate and comprehensive exam. CMS has prices affixed to each type of exam. Obviously, the comprehensive exam pays the most money while the basic exam pays the least. There are times allotted to each exam. Let’s say the comprehensive exam has a 45 minute time allotted. By sorting the procedures you can see those Doctors that see 25 people and code all visits as comprehensive. Well, 45 minutes times 25 people means the Doctor spent means he spent 11.25 hours in that day seeing patients. We all know that’s not the case so by using a simple technique exposes those Doctors billing Medicare fraudulently.
This same principle can be applied to other types of procedures, especially outpatient surgeries or other procedures where time is a factor. What is harder to spot is fraudulent billings for services not rendered.
In the June edition of the AARP Bulletin, they ran a story about Medicare fraud where one Doctor billed Medicare and Medicaid over $375 million dollars in fraudulent bills. Why wasn’t he caught sooner? If better fraud controls were in place, perhaps CMS could have caught the Doctor sooner. His fraud ran over a 5 year period.
By the way, CMS has not recovered the money. The Doctor was convicted on 8 counts of health care fraud and will be spending many years behind bars but when he comes out he still will be wealthy.
When is CMS going to get serious about Medicare fraud and actually do something?
Len Barend

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