groups

I was involved in medicare/medicaid fraud investigations for many years. There are a various defects in the system that make it easy to defraud. Primarily, the government places far more emphasis on providing service than it does on assuring efficacy and deterring fraud and mismanagement. A large metropolitan city that I was familiar with had over 200,000 of its citizens receiving benefits and had two investigators assigned to investigate fraud. I recall that they often requested assistance from our unit, but I was unable to provide more than guidance due to jurisdiction. One case they brought to me regarded a physician who had been paid for 6 hysterectomies on one woman in a one year time frame. I recall another case where my unit arrested a young mother for forging medical assistance prescriptions. We confiscated her medical assistance card and was advised by them that we had to return it to her. They could not restrict benefits regardless of what the recipient was charged or convicted of. Fraud and mismanagement accounts for a huge portion of the government health care programs and this would only escalate with a government run health care plan. I would suggest several changes in how the system is managed. 1- Every recipient should be issued one health care card for services (not one for each family member... which are often sold). 2- A clause in the application for services would include a provision canceling or restricting benefits upon conviction for criminal fraud or abuse of services. 3- More investigators assigned to monitor fraud and mismanagement (could easily be paid for in fraud and abuse savings). 4- A nationwide PMP program (Prescription Monitoring Program) where health care providers and law enforcement could use computer technology to track patients and providers who defraud the system.

How about adding some level of monetary committment on the part of the recipient? My daughter grows weary of FEMA card carriers and others on the receiving end talking on $300 cell phones, wearing tons of jewelry, making next nail salon appointments while their children are running around in designer clothes and expensive sneakers. I know there are plenty of people who need all the help they can get and I do not want them to do without needed medical care; however, the blatant abuse and the "I have a right" attitude needs to be addressed. Showing up in the ER for a "free" pregnancy test hardly constitutes an emergency. They "expect" a free taxi ride. If that fails, they call an ambulance (which you and I pay for). The burden on the health care system is causing burnout among physicians. For every doctor who scams the system, there are many more who see their income dropping below the nurse's salaries. How will we recruit doctors under Obama's plan if they know the salaries will be controlled by the pay czar. I don't look forward to medical school "graduates" who got there on affirmative action but had tests revised so they could pass. If drug companies aren't allowed a profit, who will go into research to find cures for the diseases we haven't heard of yet?? If the government panel dictates levels of care, how will new drugs get tested??

My Grandma lived to be 99 and was pretty healthy but obviously needed help the last few years. My Dad was keeping an eye on what was billed to Medicare and there were incorrect charges every single month. He also monitors the bills for anything that is charged for him and my Mom. The worst incident was a charge for enough units of blood to completely replace all the blood in my Mom's body! She actually had no units of blood in a minor surgery. He always finds incorrect billings. But it takes a lot of work on his part. First he has to get the bills and go over them, confirm that the questionable procedures were not performed, then call Medicare and report it. They ususally act like it is a bother that he reported it. Now they have to do something about it. If everyone was this diligent think how much waste could be cut out. And that's not even dealing with fraud on the part of individuals using and abusing the system.

Fraud and abuse is rampant, as JSant said in his post -- there are not nearly enough investigators to cover the problem. Also, as dafriend said, the ones who report incorrect billings are treated with disdain as if it's more of a problem to not pay the fraudulent charge than it is to just go ahead and pay it. This is an employee problem, not a fraud problem. I wonder how many fraud reports get ignored due to employee ambivalence or apathy.

There was a short TV show about this a year or so ago where some of the people on the panel said that they had incorrect billings but couldn't find anyone interested enough to do anything about it. When you have a nine to fiver on the other end of the line who will keep their job so long as they just show up at work each day, then you're never going to get anywhere with reporting fraud.

In another thread about health care, someone talked about insurance companies spending a lot of money and time trying to find any way possible to deny claims -- if the governments spent a similar amount of time and effort trying to detect fraudulent billing, they'd save more money than it cost to monitor the bills. But, when it's the government's money, the employees just don't see the importance of trying to stop the abuse.

We need, possibly, a double reporting system that is automatically monitored to make sure there's follow up -- what I mean is this. A person calls to report fraud, the report is recorded in two locations or by two people independent of each other, neither location knows who or what the other location is, just that there is another location. Then there is an audit system that checks to see if the person taking the report did what they should do - follow up - and if not, fire them! It's easy to set something like this up with the electronics and computers available today. How many times have we heard the recorded message that "this call may be recorded..." - that's all it would take. Then the person taking the call would know that the report will be monitored and there will be follow up - if not, they get fired.

The fear of losing a government job is the only incentive that the person might have to do the right thing. It would be extremely easy to set something like this up on a website that would allow people to report fraud -- have the computer automatically assign the report to two locations, and require the people at those locations to follow up, if there's no electronic indication of the proper follow up, fire 'em. I think I made my point.

Oh my this stuff is frightening,,,when people and doctors do this they take away the good for all people

I don't know if it's really the doctors. I like to think that most of the doctors, a very large percentage of them, are not involved in this fraud. Lots of times it's clinic owners who are involved in the fraud. One example was a clinic in Florida that found out that if they fraudulently billed once in a while they could afford to stay open -- in other words, trying to operate by being honest didn't bring in enough money in this poor area to pay the rent and the salaries of the employees. The clinic owners found out from another clinic owner how easy it was to submit fraudulent bills to the government. But, once they found out how easy it was, they got greedy and submitted multi-millions of dollars of fraudulent bills in a short period of time - they got caught and went to prison for a couple years and then they can try it again when they get out when they will be much smarter and more able to get away with it!

I won't argue that most health care professionals are honest and decent folks whose primary focus is to serve their patients, but it doesn't take many bad apples to have a significant impact on the problem. I recall one case of a physician in Washington DC who was diverting over 300,000 doses of a narcotic prescription drug every year. There are precious few police departments across the country who have dedicated pharmaceutical units but if you checked with them they could all stay busy just investigating health care providers. Unfortunately they also have to deal with doctor shoppers, forgers, theft and other forms of fraud. Our system was set up to provide entitlements.....not to assure checks and balances. That is something we need to correct and soon....especially if Obama expands the program and we have millions more entering the system.

Fraud is definately prevalent now. And remember, Obama wants to unionze the health care industry.