Medicare Fraud: A Recurring Trend of Pay & Chase


The internet and news outlets have been abuzz for the last 24 hours discussing yet another record-breaking Medicare fraud takedown. Just yesterday over 300 people were arrested, including 61 licensed medical professionals, were charged with various health care fraud-related crimes.

This is the largest Medicare takedown fraud in Medicare Strike Force history in terms of the number of defendants and the loss amount, which is $900 million. This nationwide sweep included 36 federal districts and 23 State Medicare Fraud Control Units assisted in the arrests.

Medicare Fraud

This is not the first or the last time we will hear of Medicare fraud. It’s just too easy to make money.

This is the first or the last time we will see a health care scam revealed. The Medicare fraud crisis is an endless one. The money you are able to make is just too easy.

A Growing History of Medicare Fraud

We are seeing multiple cases of fraud every year. With so much money to be made, it’s like an open invitation for criminal activity. It has even been suggested that crime families are getting into Medicare fraud because it is more lucrative and less risky than some of their other money making strategies.

Let’s look at some of the larger cases where we have seen the Medicare Fraud Strike Force take on the scammers:

June 18, 2015: Wednesday’s takedown broke a record set just a year and 4 days before it. In June 2015, 243 individuals were charged for scams totaling $712 million in false claims. In that crackdown, there were 46 licensed medical professionals involved.

May 13, 2014: In the spring of 2014, 90 individuals, including 27 medical professionals were indicted on charges of participating in Medicare fraud schemes totaling $260 million in bogus claims.

May 14, 2013: In one Medicare fraud takedown, 89 individuals were charged with participating in Medicare scams that resulted in about $223 million in losses. The nationwide takedown included 8 cities.

May 02, 2012: The Medicare Fraud Strike Force took down 107 people in a false billings case leading to losses of approximately $452 million. At the time, it was the largest nation takedown in history.

A Recurring Trend

These cases are just a small peek into how many Medicare scams go on a yearly basis. You could also search all the Medicaid schemes or the various prescription drug settlements and see that unless there is a change made in system oversight.

stethoscope resting on a fan of cash

Every year billions of dollars are lost. That is billions of dollars that could have potentially helped thousands of patients.

The National Health Care Anti-Fraud Association (NHCAA) estimates that every year there are tens of billions of dollars lost.

Every year.

Pay and Chase

In order to curb this healthcare fraud model, the system must change. Currently, Medicaid and Medicare operate on a ‘pay and chase’ model.

social security card and medicare enrollment form

The ‘Pay & Chase’ Medicare billing model makes it far too easy for health professionals and patients to participate in health care fraud.

This means that typically, Medicare and Medicaid will pay every bill that comes in, leaving law enforcement to have to chase the criminals that take advantage of the lax system.

The Office of the Inspector General (OIG) has encouraged the Centers for Medicare & Medicaid Services (CMS) to take action to prevent the volume of improper payments. Many ineligible or terminated providers are still able to take advantage of their services resulting in billions of dollars lost annually.

Pre-Claims Reimbursement

CMS will be able to help curb this problem by doing that, but it will not be the only way. The entire model must change to stop the problem. For those participating in these scams, jail time is worth the risk to be able to make millions and millions of dollars.

victims of medicare fraud shocked by the high cost of their medical bills

You may be a victim of Medicare schemes and not even know it. Your doctor could be billing for services you never even received.

According to a press statement released earlier this month, CMS will be taking new steps to try and combat fraud. Some health agencies in certain states will be required to “submit pre-claim documentation to ensure that services are medically necessary and all documents are properly completed and present before payment”.

The hope is that this will help stop some of the fraud and also help CMS determine what other methods or resources will be needed to reduce fraud. The pre-claims reimbursement program rollout begins in some states in August 2016, so hopefully this is a step in the right direction.

If you suspect Medicare fraud, visit Medicare’s website for instructions and information about how to report it.

Author: Locum Jobs Online

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