By Bob Moos
Southwest public affairs officer for the U.S. Centers for Medicare & Medicaid Services
The owner of a Houston area ambulance company receives a 97-month prison sentence for submitting $2.4 million in claims to Medicare for services that weren’t necessary and, in some cases, never even provided.
Two unlicensed medical school graduates each get 72 months behind bars for acting as physicians in a Dallas area house call practice and billing Medicare $2.7 million for home visits and diagnostic tests never performed.
A Houston man receives a 87-month prison term for recruiting Medicare and Medicaid beneficiaries, using their personal health information and billing the government for motorized wheelchairs never delivered.
For too long, the crooks who were behind health care fraud were often one step ahead of law enforcement. But that’s finally changing. Thanks to better coordination among federal agencies and the introduction of cutting-edge technology, more criminals are being brought to justice.
The Department of Health and Human Services and the Department of Justice now have a task force that targets areas with suspicious Medicare billings. The “HEAT Team” crime investigators sift through claims data to identify billing patterns that suggest someone has run afoul of the law.
Complementing the state-of-the-art data analysis has been some hard-nosed police work. The Medicare Fraud Strike Force – made up of interagency teams of investigators and prosecutors – now operates in nine areas known as fraud hot spots, including Dallas, Houston and Southern Louisiana.
The sophisticated detective work has paid off. Strike Force prosecutors have charged more than 2,100 defendants with fraudulently billing Medicare more than $6.5 billion. Their current conviction rate is 95 percent, and the average prison term exceeds four years.
In the past, most of the government’s anti-fraud efforts focused on chasing after taxpayer dollars only after the swindlers had stolen the money. But the Affordable Care Act has given the government more tools to keep the unscrupulous out of Medicare in the first place.
Now, more rigorous screening measures prevent fraudulent providers and suppliers from enrolling in Medicare and filing false claims. The law also lets the government suspend payments to providers and suppliers suspected of fraud until the allegations can be investigated.
Yet, as important as all these aggressive initiatives are, the first and best line of defense against fraud remains you – the health care consumer.
So here are a few ways you can protect your Medicare benefits:
- Guard your Medicare number. Fraud schemes often depend on crooks first getting hold of people’s Medicare numbers. So treat yours as you would a credit card. Don’t share it with anyone except your doctor or other Medicare-approved health care provider. If you don’t know whether a provider has Medicare approval, call Medicare at 1-800-633-4227 and ask.
- Look out for suspicious activities. Be wary of salespeople who knock on your door or call you uninvited and try to sell you a product or service. Don’t allow anyone except your doctor or other Medicare-approved provider to review your medical records or recommend services. And never let anyone give you “free” equipment or supplies in exchange for your Medicare number.
- If you have Original Medicare, check your Medicare Summary Notice. Use a calendar or personal journal to record all of your doctor appointments and tests. Then review your quarterly claims statement to make sure Medicare wasn’t billed for something you didn’t get. If you spot what you think is an error, call the doctor’s office or health care provider and ask about it. If they can’t resolve your questions or concerns, call 1-800-633-4227.
- Report suspected cases of fraud. If you think someone has misused your Medicare number, call 1-800-633-4227 or the ID theft hotline at the Federal Trade Commission at 1-877-438-4338. If you suspect Medicare fraud, call the inspector general’s fraud hotline at the Department of Health and Human Services at 1-800-447-8477.
Fraud isn’t a victimless crime. Illegal schemes waste tens of billions of dollars each year and drive up everyone’s health care bills. If we’re to protect Medicare from fraud, we all need to pitch in.