Miami Herald | EDITORIAL

The big sweep


OUR OPINION: Enhance resources to fight Medicare fraud — the crackdowns are working

More than half of the people arrested in six cities across the country and charged with Medicare fraud this week were from South Florida. Of course — we’re No. 1, but not in a good way.

In South Florida, 50 suspects were nabbed in the two-day operation, charged with trying to pocket almost $66 million from the federal healthcare program. It’s greed gone wild — and it comes at the expense of taxpayers, honest medical providers and, worst of all, elderly patients who got bogus care — if they got any care at all — and medications they don’t need.

The take-down was commendable and encouraging — the result of strong partnerships among the U.S. Department of Justice, the Centers for Medicare & Medicaid Services (CMS), the law-enforcement community, including the FBI, and the legal community, plus new provisions courtesy of the much-maligned Affordable Care Act — Obamacare. The law offers new technical tools to help prevent Medicare fraud and imposes way tougher restrictions on who can be a Medicare provider.

For all these strides, however, resources remain stretched and unable to catch even more fraudsters in this ever-fertile region for such bold and, unfortunately, lucrative deception — or stop them before they get started.

As reported by the Herald’s Jay Weaver, in addition to the usual suspects nabbed in such sweeps — doctors, nurses and squirrelly clinic owners — this time around, 37 of those arrested were “patient recruiters.” They stand accused of pocketing thousands of dollars in bribes for supplying Medicare beneficiaries to crooked home-health agencies, mental health clinics and pharmacies. On top of that, patients themselves, accused of taking kickbacks to let their Medicare cards be fraudulently used, are among those swept up in the bust.

Discouraging, yes, but there also is cause for cautious optimism. Because of increased law-enforcement muscle and focus there has been a stunning decline in false billings. According to U.S. Attorney Wifredo Ferrer, the home-health industry and mental-health services have been especially ripe areas for fraud and abuse. In 2008, in Miami-Dade County alone, he told the Editorial Board, there was $1.4 billion in Medicare billings for home-health services. After a crackdown that netted 24 suspects between 2009 and 2012, billings dropped 38 percent.

In 2009, Medicare billing reached almost $360 million for mental-health services in Miami-Dade. With some high-profile prosecutions — and convictions — billings have dropped to $20 million a year, a 94 percent plummet.

This is the only region that has a stand-alone facility where prosecutors, medical professionals, CMS the FBI and other agencies work side by side evaluating data. With new technology and data available through the Affordable Care Act, they can review billing claims almost in real time, giving them a greater ability to keep fraudulent claims from being paid.

This is significant. By law, claims must be paid within a certain time period, too often, far sooner than it might take to determine whether they are fraudulent. Once the money is paid out, the chase to get it back can be a fruitless waste of time, effort and money.

Going forward, lawmakers should re-examine the efficacy of the payment deadline. It’s imperative, too, that the resources, including data-analysis technology, to tackle the scourge of Medicare fraud are enhanced. In this case, there’s no pride in being No. 1.

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