Health Care

Medicare fraud is a multibillion-dollar industry. Here’s how to spot it and report it.

Federal agents with Health and Human Services, the FBI and IRS carried out a nationwide takedown of healthcare fraud offenders in June.
Federal agents with Health and Human Services, the FBI and IRS carried out a nationwide takedown of healthcare fraud offenders in June. U.S. Department of Health and Human Services-Office of Inspector General

In June, the Department of Justice and United States Attorney’s Office released details of the nation’s largest ever healthcare fraud takedown, led by the Medicare Fraud Strike Force.

The charges and arrests involved 601 people, including doctors and other licensed medical professionals, spanning 58 federal districts responsible for $2 billion in false billing.

These fraudulent schemes involved home healthcare, substance abuse treatment, lab testing and pharmacy fraud, including the distribution of illegal opioid prescriptions.

The announcement included 124 individuals and $337 million in false billing across the Southern District of Florida alone. South Florida is the leader in healthcare fraud indictment and seizures, according to Michael Sherwin, assistant U.S. attorney in the Southern District of Florida.

“Other districts learn how to prosecute these cases from us,” he says.

Geographically, the Southern District of Florida is one of the largest, spanning more than 15,000 square miles and nine counties from Key West to Sebastian and Sebring in Central Florida.

As a haven for retirees, South Florida is a particularly “target-rich environment” vulnerable to fraud aimed at Medicare, the federal health insurance program passed in 1965 by President Lyndon B. Johnson that provides hospital, medical and prescription drug coverage to citizens over age 65, as well as the disabled.

Areas in Palm Beach and Broward counties have also seen an uptick in fraudulent practices at sober homes that work with clinics where addicts are not receiving appropriate treatment, therapy or drug tests, and insurance companies are falsely billed.

“These are the most egregious cases because there’s direct harm to vulnerable victims,” says Sherwin.

Established in 2007, the Medicare Fraud Strike Force targets all types of healthcare fraud including private insurance, but Medicare gets the most attention because of the sheer size of the program and its beneficiary pool. Today, 59 million people, or roughly 15 percent of the U.S. population, are enrolled in Medicare and that number is expected to grow to 79 million by 2030.

The fraud schemes are often elaborate and involve a chain of bad actors.

“You can have one dirty physician or therapist working across a broad spectrum with 20 different clinics where he’s signing [false] patient forms and prescriptions,’’ Sherwin said. “It doesn’t take many people to make this engine go.”

Clinic owners also work with patient recruiters to drum up confidential information that is then used for false billing.

“The victim is the taxpayer in the great bulk of these cases,” says Sherwin. “It’s overbilling and it’s a multibillion-dollar problem.”

How to spot Medicare fraud

How can you tell if you’re a victim of Medicare or healthcare fraud?

Sherwin puts it plainly: “It’s basic things. When you get your bill, look at it.”

Review your claims for errors and follow up with your healthcare provider.

Report anything suspicious to the Medicare hotline at 1-800-MEDICARE.

Sherwin says people are less vigilant with their Medicare claims because they think the government is footing the bill.

“At the end of the day, we’re all victims. We’re all paying by supporting these programs with billions a year [in tax dollars],” he says.

How to prevent Medicare fraud

“It’s the same as credit card fraud or identity theft. Protect your personal information,” says Sherwin. “If someone calls you on the phone and says they’re a doctor from a clinic and they need your credit card number, your banking information, your Social Security number, your Medicare number, that’s a red flag.

“Hang up. That’s confidential information that should only be shared with your medical provider [in person].”

Medicare will never solicit that information over the phone. Similarly, do not entertain door-to-door solicitations from anyone claiming to represent Medicare and don’t let anyone persuade you to see a doctor for care you don’t need.

It’s smart to keep a record of the dates of your doctor visits, treatments and procedures to check against your Medicare statement for accuracy. At the pharmacy, ensure that the pharmacist fills the correct prescription in full.

How to report Medicare fraud

If you think you are a victim of Medicare or healthcare fraud, contact one of the below resources:

Call 1-800-MEDICARE

Call the Office of the Inspector General at 1-800-HHS-TIPS

Fill out the online form

Visit Medicare.gov

Ensure that the following information is handy: the provider’s name and any identifying numbers, the service you’re questioning, the date of the service, the payment approved by Medicare, your Medicare number and the reason you think Medicare should not pay.

“What’s satisfying with these cases is that we know for sure there’s a direct impact on the community,” says Sherwin.

The strike force is responsible for returning over $3 billion to Medicare.

“Anytime there’s massive amounts of federal money allocated, there is always going to be fraud. There just is,” he says. “There are vulnerabilities and all we can do is try to identify these vulnerabilities and seal them off and try to make them better.”

  Comments