Putting an End to Medicare Fraud

When Medicare was signed in to law by President Johnson in 1965, it was intended to serve as a central funding resource for persons over 65 years, and people with disabilities. Over the years millions of people have benefited from the financial medical pool that Medicare is — providing healthcare resources to innumerable people in need. There is no denying that the founders’ vision and efforts are truly commendable. However, every coin has two sides to it, and of late the ugly side of Medicare has been rearing its head. Fraudulent healthcare practices by healthcare companies and individuals abusing their benefits have contributed greatly to the depletion of Medicare reserves. Senate Republicans estimate that frauds cost Medicare and Medicaid approximately 60 billion dollars annually.

The face of the offender in Medicare crimes is diverse, ranging from the small time swindler to the highly qualified surgeon. Setting up pseudo healthcare companies, intentionally entering false claim codes, billing for time that was not spent with the patient, and billing for unnecessary equipment are all techniques that have been used in racketing schemes that request “reimbursement” from Medicare. Home health care is another venue where Medicare fraud may occur. I have heard casual, subjective reporting from patients of professionals spending only 10 minutes in actual patient care activities, and billing for the entire hour. The area of providing home medical equipment also may be targeted, vendors may request more accessories on a wheelchair than is medically necessary and claim costs from insurance, or recommend more than one assistive device.

WheelchairThe Centers for Medicaid and Medicare Services (CMS) have responded to this issue by initiating a revamped auditing system, by contracting out the auditing process to independent companies. The pilot project was spread over three years and three states, during which time about $980 million in overpayments were identified, and $13 million reclaimed. This auditing process has triggered off strong disapproval amongst physicians. They claim that the auditors are aggressive and tend to barge in during appointments. They also complain about the cost that they incur (in terms of phone calls and mailing costs) when they have to retrieve and resend paperwork to the CMS.

I used to shudder at the thought of completing documentation for Medicare — my boss even joked that understanding Medicare paperwork was comparable to reading a rocket science textbook. But I see the value standardizing the claims processes, and asking for comprehensive documentation. What might inconvenience a few healthcare professionals will ultimately contribute towards keeping the Medicare pool viable for the future generations.

Nirupama Shankar, PT, MHS

Nirupama Shankar, PT, MHS, is a physical therapist by profession, and has over 7 years of clinical experience in the field of neurological rehabilitation. She has treated individuals with stroke, traumatic brain injury, spinal cord injury, Parkinson's disease, multiple sclerosis, and amputations. She has also completed training modules and community education projects in Michigan and North Carolina.
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