Medicare for All: What to be done to reduce fraud?

[MandaJo]

@doreen

I’m sure the providers are the main source of Medicare fraud - but as far as the patients go , if 60 year old grandma takes her 65 year old sister’s Medicare card to a new doctor, how will they know it’s not hers? Some offices have asked for ID if I’m a new patient, but not nearly all.

I have never ever ever not been asked for ID the first time I had an appointment with a provider, and every time if it’s urgent care or anywhere where they don’t know me.

[wolfpup]

@Velocity

Maybe Canada just runs a much tighter ship or the USA is just more prone to fraud. But going by the figures in that CBS article, it look like American Medicare fraud runs at about 11-12% of the costs compared to the two percent of Canada’s.

In terms of running a tighter ship, I’m surprised to hear anyone even discussing the possibility of using someone else’s health card. In Ontario and every other Canadian province that I know of, health cards are issued through the same government offices that issue driver’s licenses and use the same technology, including the user’s photo and other security features. No one would be asked for ID when presenting a health card because a health card is ID. Apparently the unauthorized use of other people’s health cards is the main reason they switched to the new high-security cards. I don’t think fraud was a major problem even then, but this reduces it further.

I would suspect many other factors, too, related to single-payer vs the US system. When there is only one direct single payer, it’s much easier to pick out unusual charging patterns. And because US health care costs are so astronomically high, there’s more profit and incentive to conduct unnecessary tests, especially if the doctor has a financial stake in the medical lab (procedures like MRIs can literally cost ten times what they do in Canada). For-profit hospitals are rampant throughout the US, whereas almost all Canadian hospitals are non-profits.

[Ruken]

@Gyrate

Yes, this is kind of important. If the “fraud” you’re trying to prevent is people not eligible for the system fraudulently claiming that they are, making everyone eligible eliminates all that fraud in one fell swoop.

I think only confused people are writing about this.

[FinsToTheLeft]

As people have mentioned, there are two types of fraud:

[ol]
[li]Patients who are not eligible getting treatment[/li][li]Health Care Providers claiming for procedures they are not eligible for[/li][/ol]

In Canada, item 1 is greatly reduced because everyone legally resident in Canada is entitled to health care treatment. Fraud is limited to non-residents trying to get treatment. This includes people who are Canadian citizens but do not live in the country, but try and get medical treatment. If I moved to the US, say on a green card, I am no longer eligible for OHIP coverage (Ontario’s implementation on UHC). I need to move back to Ontario and be resident for 3 months before I regain coverage. This does not stop people from keeping and renewing their health card every 5 years.

Item 2 will exist anywhere there are lazy or unethical providers. Claim for additional services not rendered, “upgraded” services - treatment vs consult, or sheer made up claims. This still happens here, but I think it’s easier to catch since we have single payer the fraud is not spread around and the trends show up more quickly.

[snowthx]

@mikecurtis

why are you singling out medicare fraud? Med ins fraud in the private sector accounts for 3% - 10% of claims, which is $90B - $300B per year. And while Medicare’s 9% is near the top it’s still within the range.

https://www.nhcaa.org/resources/health-care-anti-fraud-resources/the-challenge-of-health-care-fraud/

I agree with this thinking. Medicare fraud is about on-par with commercial insurance fraud, so I would expect the same processes and procedures to be in place today that insurance companies use (mainly, back-end auditing and collections, as well as law enforcement). Sure, it’s not perfect, and could be improved, but I question the idea that Medicare is rife with fraud while commercial-grade insurers are much better at preventing/mitigating it. That is not a good assumption.

[Voyager]

@PastTense

I think it will be a lot easier to pick up the patterns since Medicare will be paying for almost all of it: for example you can see that it will be impossible for a doctor to be treating this many patients–there aren’t enough hours.

I’ve worked on data analysis and I think this is exactly right. Most fraud I’ve heard of has been concentrated in a small number of doctors who bill for procedures not performed. Since the patient is not getting billed, the patient is not going to notice.
It would be fairly easy - with all payment coming from one place - to build models of what doctors in specific regions and with specific specialties are expected to bill, and investigate discrepancies.

[puddleglum]

@Voyager

I’ve worked on data analysis and I think this is exactly right. Most fraud I’ve heard of has been concentrated in a small number of doctors who bill for procedures not performed. Since the patient is not getting billed, the patient is not going to notice.
It would be fairly easy - with all payment coming from one place - to build models of what doctors in specific regions and with specific specialties are expected to bill, and investigate discrepancies.

That sounds so easy but yet it is not being done now. Why not? You would think politicians would be more interested in a free $50-100 billion per year.

[doreen]

@puddleglum

That sounds so easy but yet it is not being done now. Why not? You would think politicians would be more interested in a free $50-100 billion per year.

I think the idea is that it’s not easy with payments coming from different places- no one entity has all the data.

[Voyager]

@puddleglum

That sounds so easy but yet it is not being done now. Why not? You would think politicians would be more interested in a free $50-100 billion per year.

Because doctors don’t only bill Medicare. I suspect they are finding really blatant cases, but it is hard to do these kinds of studies if you have only a fraction of the data. Especially since you don’t even know what percentage of the data you have.

[Northern_Piper]

@puddleglum

That sounds so easy but yet it is not being done now. Why not? You would think politicians would be more interested in a free $50-100 billion per year.

You would think politicians would be interested in leveraging their position as purchasers of medications for VA and Medicare to get better deals and save money on medications those agencies buy, but Congress has barred the VA and Medicare from doing that.

Don’t assume rationality in the US health care system.

[Northern_Piper]

@PastTense

I think it will be a lot easier to pick up the patterns since Medicare will be paying for almost all of it: for example you can see that it will be impossible for a doctor to be treating this many patients–there aren’t enough hours in a workday.

Based on news stories I’ve seen occasionally, that’s exactly how [del]fraud[/del] over-billing is caught in the Canadian process.

Since there’s only one payer, and it’s all computerised, the Medicare officials find auditing very easy: «Computer! Give us all the bills filed in Town X for ear-wax cleaning in 2019!»

Je he computer spits out the info, and Dr Jones is off the charts for ear-wax cleaning. No other doctor in Town X has such a high rate.

So the bean-counters say «Computer! Give us all the bills filed by all Doctors in the Province for ear-wax cleaning!»

And Dr Jones is again off the charts.

So Dr Jones will get a visit from the auditors. Maybe it turns out that Dr Jones has invented a new marvellous technique for ear-wax cleaning, and is getting tonnes of referrals from other doctors, of patients with stubborn ear-wax blockages.

Or maybe Dr Jones is cheating the system.

Either way, the auditors for a single-payer system have a strong advantage over auditors in a private insurance system.

And that drives down rates of fraud (not Bryan Eckers´s theory about nice Canadians - sorry, Bryan. )

Criminologists have long been telling us that one of the best factors driving down criminal behaviour isn’t the severity of the punishment, but the chance of getting caught. If single-payer gives auditors better tools for catching fraudsters, then that drives down fraudulent behaviour.