Health Law Gives Medicare Fraud Fighters New Weapons
Fighting health care fraud in the U.S. can seem like an endless game of Whack-a-Mole. When government fraud squads crack down on one scheme, another pops up close by.
But the fraud squads that look for scams in the federal Medicare and Medicaid programs have some new weapons: tools and funding provided by the Affordable Care Act.
Medicare and Medicaid pay out some $750 billion each year to more than 1.5 million doctors, hospitals and medical suppliers. By many estimates, about $65 billion a year is lost to fraud.
"For a long time we were not in a position to keep up with the really sophisticated criminals," said Peter Budetti, who oversees anti-fraud efforts at the Centers for Medicare and Medicaid Services. "They're not only smart, they're extremely well-funded. And this is their full-time job."
And their creativity is endless. Criminals use real patient IDs to bill for wheelchairs that were never delivered or exams never performed. Dishonest doctors — a small percentage of physicians, to be sure — charge for care they never deliver or perform unnecessary operations. In one scam, criminals bill Medicare and a private insurer for the same patient.
But if crooks are smart, it may turn out that computers are smarter. The federal health law and other legislation directed the federal government to start using sophisticated anti-fraud computer systems. Budetti said the systems, which are being used first with Medicare, are similar to those used by credit card companies to detect suspicious purchases.
This doesn't surprise me in the least and i’d be willing to bet a lot more, I used to work for an TPA in health insurance and would see stuff all the time I can only imagine what it’s like through medicare/caid and other insurances, doctors and hospitals. It's crazy, and it was before they had any real laws where passed, I would find so many errors and falsifications in the medical claims/billing alone just by paying attention and knowing codes and ICD9's. I didn't need a computer to point it out.
Channel 2 Action News learned later Monday afternoon, a judge ordered a local medical equipment manufacturer to pay out more than $48 million in a
A judge ordered C.R. Bard to pay out after Julie Darity, from Macon, said she was eventually fired by Bard after she started noticing kickbacks for hospitals involving cancer treatments.
“I think it’s the largest kickback case in Georgia history,” attorney Marlan Wilbanks told Channel 2′s Craig Lucie.
Wilbanks said C.R. Bard overcharged dozens of hospitals around the country for prostate cancer seeds.
Q. Does private insurance or Medicare cover seed implantation?
A. Both private insurance and Medicare will pay for this procedure.
During interstitial brachytherapy, devices containing radioactive material are inserted directly into body tissue. One treatment for prostate cancer involves placing radioactive seeds into the prostate.
Prostate Cancer Risk Factors
Race. Prostate cancer occurs about 60% more often in African American men than in white American men and when diagnosed is more likely to be advanced. However, Japanese and African males living in their native countries have a low incidence of prostate cancer. Rates for these groups increase sharply when they immigrate to the U.S. African Americans are the second group of men for whom prostate cancer testing should begin at age 40.
The radioactive seeds allow doctors to treat patients by limiting the amount of damage to surrounding tissues.
Wilbanks said C.R. Bard overcharged dozens of hospitals around the country for prostate cancer seeds.
The radioactive seeds allow doctors to treat patients by limiting the amount of damage to surrounding tissues.
One patient may have 40-100 seeds implanted.
The lawsuit alleged that when hospitals complained about the high price of the seeds, Bard told them to pass the charges onto Medicare.
By doing this, Wilbanks said Medicare would then pay Bard.
In return, attorneys said Bard would then kick back some of the money to the hospitals along with some other perks.
“Some were financial grants given to the hospitals, some were equipment, equipment maintenance,” Wilbanks said.
No comments:
Post a Comment