This seems to be a huge issue that liberals and conservatives ought to be able to both unite on in bipartisan fashion; liberals; because billions of dollars in fraud are adversely affecting Medicare, and conservatives, because they tend to decry fraud and waste.
Yet I see little fuss being made over what ought to be a huge issue. Why aren’t more politicians and journalists speaking up about this? Are they afraid to criticize Medicare fraud, for fear of somehow appearing “anti-Medicare?”
What do you expect them to say that will make a difference? I assume people in the government our working on it, as your links establish. I’m sure if they’re asked, they will criticize Medicare fraud, as well as most other crimes.
“Medicare fraud is bad.” There, I said it.
Medicare is a good model for single-payer because of its efficiency. We should extend it to everyone in the country, and thereby automatically cut costs. Or not.
Regards,
Shodan
Let’s cut the real fat- let Medicare negotiate prescription drug prices with the manufacturers.
The GAO says that improvements are being made and that fraud may be roughly 50 Billion out of 604 billion spent (~8%).
The question, aside from whatever improvements are going on, is just how many people and associated costs would people be comfortable with to move the fraud rate from 8% to 5%. Keep in mind that would only drop the losses to 30 billion from 50.
Hell, assume an auditor with a loaded labour rate of 200k can recover 2 million a year. You would need 10000 people. Then add in their 600 odd managers (say 1:15) and then their 60 directors and 10 senior directors and 1 general manager.
Would it be worth it? It would be around 2 billion.
http://www.wsj.com/articles/why-its-so-hard-to-fix-medicare-fraud-1419559442
No system is leakproof. You need to decide how much leakage is acceptable. They’re working on reducing fraud, but the vast majority of legitimate users still must have access to medical care.
<Republican> No!!! We can’t increase the size of government </Rep>
Remember, these are the people who crow about cutting the IRS budget.
I think the reason we won’t see liberals and conservatives agreeing on anything other than a high level statement that Medicare fraud is bad is because both sides would blame it on different things. It is providers perpetrating the fraud, sometimes with and sometimes without aid from Medicare recipients. That would presumably be the larger focus of liberals. It is government oversight that enables the fraud, and that would presumably be the larger focus of conservatives. That said, I think most would agree that both are a problem.
It’s also hard to compare private insurance fraud rates with Medicare since they work so differently. Insurance companies have a huge financial incentive to catch and discourage fraud, but it comes at the expense of customers in that Americans spend such a high amount per healthcare dollar on administrative costs rather than the actual care. In other words, administrative costs of Medicare are likely much lower than private insurance while fraud rates are higher, and private insurance is likely the reverse. If you simply compare fraud rates you are missing the forest for the trees. At some point, spending money to reduce fraud will cost more than allowing the fraud, in addition to impacting legitimate patients and claims. If you have had private insurance and made claims, it’s very likely you’ve experienced this administrative overhead when claims are postponed or initially denied even when they are legitimate.
All that said, I’d love to see a good study comparing fraud rates between Medicare and private insurance. Surely there are plenty of unscrupulous providers who commit fraud against private insurance just as there are for Medicare.
Establish heavier penalties, raise more attention in the media, be slower to hand out Medicare benefits in suspicious circumstances.
I’m confused, do you mean, spend $2 billion to reduce $30 billion in fraud? …Because it sounds like it would of course be worth it.
Sorry, I mean 20 billion (50 billion minus 30 billion.)
$2 billion to save $20 billion…and at the same time, Granny goes without nursing care because we can’t document to their satisfaction that she really needs it.
I work in home health, for Medicare patients. While there is, sadly, a lot of fraud in my industry, there’s also a lot of denials for legitimate claims because of nitpicking and a failure to read the entire note.
I’ve had claims denied because a doctor forgot to write the date a Face-to-Face Encounter, even though it was on his visit note. Nothing was wrong with the whole rest of the episode, but one missed date on one piece of paper got a chargeback for two months of visits.
I’ve had claims denied because a doctor wrote “Homebound d/t CHF, SOB min exert, fatigue/gen weak d/t CKD st 5, BKA RLE, wheelchair” instead of “Patient is homebound because of shortness of breath with minimal exertion due to congestive heart failure creating low oxygenation to tissues, fatigue and generalized weakness related to stage 5 chronic kidney disease and a below the knee amputation on right lower extremity with dependence on an adaptive device (wheelchair) creating a considerable and taxing effort to leave the home.” Same information, both versions totally support and document homebound status by Medicare guidelines, but the approved form took ten times as long to write.
I’ve had claims denied because a patient with Alzheimer’s disease took too long to learn when and how to take her medications for diabetes. The denial was based on the fact that I’d charted I taught her when and how to take her medications, and they completely ignored the part that said her return demonstration was ineffective and further teaching, as well as obtaining a pill box with an alarm, were required for safety and medication management.
So yes, by all means, we need to cut down on Medicare fraud in our industry. We nurses have to refuse to certify patients as homebound when they aren’t, even if the doctor said they are (and vice-versa). We have to work hard to meet discharge goals, instead of half assing it so we can get another certification period out of them. We have to report agencies for opening cases and billing for 2 months of care when they never show up again. But we also have to work to make sure that people who really need care don’t get denied that care.
There are two major problems with the implied message in that bit of snark.
The first problem is the fact that Medicare has to co-exist with a private insurance system. This makes it enormously complex and inefficient for that very reason. The whole virtue of single-payer is how simple and streamlined it is. You need medical care, the government pays for it, end of story. Medicare is nothing like that – it’s quite literally the opposite in that respect – the kind of system that quite frankly makes my head hurt when I try to fathom some of its tremendously complex intricacies and options.
The second problem is that the intrinsic lack of oversight over medical providers arising from the private insurance system has created a profiteering medical care delivery system that is a fertile breeding ground for fraud. The fact is that there is surprisingly little fraud in, for instance, Canadian provincial single-payer systems, despite the fact that claim payouts are pretty much automatic and indeed highly automated.
Your snark betrays a deep lack of understanding of single-payer.
Really? I made an assumption of every auditor recouping x10 their LLR. Is that reasonable? Ultimately you’re servicing the public and you need to determine at what point your efforts to reduce fraud interfere with providing the service.
Are you saying that single payer can only work if it has no competition?
In any case, fraud should be counted as “overhead” when comparing public health care costs to private. As for why it’s not a big issue, nothing our bureaucracies do are issues, because we don’t vote for the bureaucracies and the people we do vote for claim they are not responsible for what the bureaucracies do. So we no longer live in a democracy, because almost all of the decisions are made by bureaucracies that are not accountable to voters.
However, we can make a big issue out of THAT. The Medicare fraud problem is just one part of a larger problem, unaccountable bureaucracies. Congress should pass aggressive oversight laws, starting with a law to make failure to address deficiencies found by the GAO or IGs result in automatic pay cuts to all workers in the agency. A written plan to address deficiencies with timetables, benchmarks, and the officials accountable for implementation of the plan must be submitted to Congress. Failure to accomplish the plan will result in automatic firing of the responsible officials.
Right now, we have watchdogs, but they have no bite. They issue reports about fraud, waste, abuse, mismanagement, and borderline corruption and if we’re lucky, the press might report on some of it. If it’s a big enough scandal, THEN maybe something is done about it. It shouldn’t take a national scandal. Problems should be addressed as soon as the watchdog agencies report on them. Presidents should also be required to read and sign all GAO and IG reports deemed “serious” in nature(use a classification system like the State Dept uses for classified info to decide what is serious and what is minor). That way a President can never again claim that the first he heard about major problems in agencies he oversees is when he read about it in the newspaper.
Here’s what the GAO said about Medicare fraud:
Specific plans follow. Then:
The GAO needs teeth. We have all kinds of federal agencies that take draconian enforcement actions against every day citizens. The GAO should have the power to take the same types of enforcement actions against the agencies it oversees. The GAO shouldn’t be making suggestions, the GAO should have regulatory power and the ability to punish federal officials and agencies who fail to implement the regulations GAO issues.
No. That’s a fundamental misreading or mischaracterization of what I’m saying. Single-payer or its functional equivalent competes with private insurance in many countries, indeed in most.
I’m saying that in the US Medicare has to co-exist with – that is, actually interoperate with – the whole broken landscape of private insurance – it actually uses private insurance in many ways – Medicare Advantage, the need for additional private coverage because Medicare sucks, etc. The complexity is staggering – Medicare Part A, Part B, Part C … seemingly through the whole alphabet – donut holes, premiums, deductibles, limits – my head begins to spin.
I can’t emphasize this enough: I’ve lived under single-payer my whole life and I can’t remember ever even seeing a medical insurance form – what would it be for? If I’m sick the government pays the bill. It’s not complicated at all. That’s what I’m saying. And there’s no significant fraud, because the entire model of freewheeling profiteering that goes on right under the nose of the private insurers simply doesn’t exist. I know this is anathema to conservatives, but we’re talking about health care, not vacuum cleaner sales. The approach needs to be fundamentally different.
What if they put a bounty on the metaphorical heads of fraudsters? If most of the fraud is being done by healthcare providers rather than individuals, I imagine most of the fraud operations (large ones anyway) involve multiple people. It would be very risky to set up a large operation if any of your employees can turn you in for a big payday.
(Or are there rewards already?)
I don’t understand how this is a problem that cuts down party lines. People who defraud Medicare are criminals. Not Republicans, not Democrats. Criminals.
True, but there are those who fear that accountability and a crackdown on Medicare would lead to legitimate Medicare users being denied or delayed benefits.
One of the two political affiliations is probably more likely to harbor this fear.