medicare fraud

Legal nurse consultants can help thwart Medicare fraud.

When does Medicare fraud happen? Typically, this occurs when a health-care provider knowingly bills Medicare for goods or services that were not provided, or when a person uses someone else’s Medicare information to obtain goods and services they are not entitled to. Some beneficiaries may sell their Medicaid number to others who submit bills for health goods and services that were not provided.

Medicare Fraud – Cost of Crime

We all know what Medicare fraud is but did you know that recent statistics suggests that Medicare loses more than $60 billion per year because of this white collar crime? That amount of money would pay for almost half of all full-time college students in the country for a two year or four program! These scams are so lucrative they have even surpassed cocaine dealing as the major criminal enterprise in Miami, Florida.

Because all scammers take pride in their work, they develop creative ways to pursue their ill-gotten gains, such as ambulance operators making phony trips, a fake pharmacy or medical clinic from a cheap office front, shipping unwanted penis enlargers to diabetes patients and billing for personal expenses such as jewelry, cars and vacations.

Consider these behaviors Medicare fraud:

  • Partially filling prescriptions, but charging as if a full prescription was provided.
  • Giving or accepting something in addition to normal reimbursement from a patient, other health care provider, or insurer in return for medical services. This is known as a “kick back”.
  • Prescribing medications, drugs, or treatment that are not medically necessary.
  • Charging Medicare or Medicaid patients a higher rate than others for the same prescription.
  • Knowingly providing defective products or services.
  • Falsely diagnosing a more severe ailment than the one the patient actually has. This is known as “upcoding” a diagnosis, thereby justifying a more expensive drug therapy or other treatment than that which the patient’s health requires.
  • Inappropriate changes in patients’ prescriptions from one drug to another as a result of kickbacks or for other improper reasons.
  • Paying beneficiaries with no health problems to make unnecessary visits.
  • Fabricating claims from nonexistent clinics, patients or deceased patients.
  • Changing a diagnosis or treatment code to secure a higher reimbursement.
  • Billing for services not actually performed, known as “phantom billing”.
  • Embezzlement of recipient funds.
  • Billing more than one services that should be combined into one. This is known as “unbundling”.

 Fighting Thieves

So how do we fight them? Various vendors have developed software for identifying several indicators of fraud. These systems can identify providers who consistently submit questionable claims, it recognizes patterns within individual claims, without reference to the provider, which immediately stops the claim for further investigation and a claim is scored based on its deviance from the “norms” established by  the provider and the patient over an established period of time.

whAnother tool is electronic health records which allows monitoring of diagnosis, doctor’s visits, laboratory services, medical history and drug data. It can also electronically prescribe and request drug and medical prior authorizations.

While new age technology can identify patterns there by eliminating some fraud, common sense, physical investigation and old fashion leg work has its advantages too. In one case a hidden camera recorded a very active and healthy 82 year old grandmother telling her doctor she was in good health, yet official documentation indicated she was homebound, needed assistance in all activities and was unable to safely leave home. Recently in 2011, a 9 state raid involving health care facilities arrested more than 100 doctors, nurses, therapists and healthcare executives for racking up more than $200 million in fraudulent services and medicines never received. In Houston a nurse was sentenced to 8 years in prison after she was convicted for her participation in a fraud scheme that netted over $5 million.

Medicare fraud is serious business with serious consequences for both legitimate providers and unethical healthcare professionals. The lure of easy money will draw thieves from all walks of life. All participants in the insurance and medical care arenas need to be aware and on guard for supspecious activity of any kind.  We all must be vigilant, educated and dogged in your pursuit of protecting your assets medical and claim information. With new technologies, software and dedicated investigators you too can bust the scammers.

Nurse Case Managers and Legal Nurse Consultants – Fraud Cops

The use of Nurse Case Managers and Legal Nurse Consultants are two ways that carriers, self insureds employers are using these traditional roles in more non-traditional ways.  Nurses are well versed in understanding the nuances of medical care.  From medications to hospital care to evolving outpatient care strategies; nurses are a GREAT place to start for getting a handle on claims dollars and questionable provider/patient/injured worker activities and/or billable items.  While the latest technology is great, sometimes good old fashion team work is the way to go.  If you have not tapped into your case manager or legal nurse consultant lately, you just might be missing out on invaluable information.