# Medicare fraud: Why isn't it a high-profile issue? **URL:** \ **Category:** Great Debates\ **Created:** [August 18, 2015, 4:36pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187 "2015-08-18T16:36:18Z")\ **Posts on this page:** 20\ **Page:** 2
**Author:** ![adaher](https://avatars.discourse-cdn.com/v4/letter/a/dec6dc/32.png) [@adaher](https://boards.straightdope.com/u/adaher)\ **Post date:** [August 19, 2015, 3:11pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/21 "2015-08-19T15:11:36Z")
There’s also the fact that anti-fraud measures are administrative costs that make Medicare look less cheap. Medicare seems better than private care if you don’t count fraud as a cost. ---
**Author:** ![ralph124c](https://avatars.discourse-cdn.com/v4/letter/r/8797f3/32.png) [@ralph124c](https://boards.straightdope.com/u/ralph124c)\ **Post date:** [August 19, 2015, 3:17pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/22 "2015-08-19T15:17:21Z")
Forget Medicare-what about the 6.5 million people receiving SS, all over 112 years old? Link:[http://www.newsmax.com/US/ssa-audit-millions-dead/2015/03/10/id/629253/](http://www.newsmax.com/US/ssa-audit-millions-dead/2015/03/10/id/629253/) ---
**Author:** ![adaher](https://avatars.discourse-cdn.com/v4/letter/a/dec6dc/32.png) [@adaher](https://boards.straightdope.com/u/adaher)\ **Post date:** [August 19, 2015, 3:20pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/23 "2015-08-19T15:20:04Z")
And again, an Inspector General makes a report noting a serious deficiency and nothing is going to be done about it. The illegal immigrants who have stolen these numbers should be deported to Albania. ---
**Author:** ![Algher](https://avatars.discourse-cdn.com/v4/letter/a/3d9bf3/32.png) [@Algher](https://boards.straightdope.com/u/Algher)\ **Post date:** [August 19, 2015, 4:04pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/24 "2015-08-19T16:04:03Z")
> [@WhyNot](#): > > $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. This - all of this. A lot of what is labeled fraud in those reports includes these types of cases. The Medicare paperwork trail is there to prevent fraud, but it also creates fraud where none truly exists. There is a reason that there are consultants who work with medical practitioners (for a price, of course) to help them safely file and code for reimbursement. The note taking requirements, the fact that the same procedure can be coded in multiple ways, the issue of “you forgot to put X on the top of the sheet”, etc. makes Medicare (and Medicaid in many states) a dangerous proposition for some doctors. Is there fraud? Absolutely. Is there a need to make this a smoother process for providers? Absolutely. ---
**Author:** ![GrumpyBunny](https://avatars.discourse-cdn.com/v4/letter/g/bc8723/32.png) [@GrumpyBunny](https://boards.straightdope.com/u/GrumpyBunny)\ **Post date:** [August 19, 2015, 4:52pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/25 "2015-08-19T16:52:31Z")
> [@Algher](#): > > The note taking requirements, the fact that the same procedure can be coded in multiple ways, the issue of “you forgot to put X on the top of the sheet”, etc. makes Medicare (and Medicaid in many states) a dangerous proposition for some doctors. I’ve run into the same mindset within any insurance company where prior authorization or medical review is needed. Oh, you wrote down that the patient is taking X, Y, and Z? Well, you didn’t check the little box telling us you wrote it down, so denied. Very common everywhere. ---
**Author:** ![WhyNot](https://avatars.discourse-cdn.com/v4/letter/w/c77e96/32.png) [@WhyNot](https://boards.straightdope.com/u/WhyNot)\ **Post date:** [August 19, 2015, 5:02pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/26 "2015-08-19T17:02:39Z")
> [@GrumpyBunny](#): > > I’ve run into the same mindset within any insurance company where prior authorization or medical review is needed. Oh, you wrote down that the patient is taking X, Y, and Z? Well, you didn’t check the little box telling us you wrote it down, so denied. Very common everywhere. True, and should likewise be stopped or at least minimized. But Medicare makes it much more difficult to file and win an appeal than most private insurance. ---
**Author:** ![dracoi](https://avatars.discourse-cdn.com/v4/letter/d/90db22/32.png) [@dracoi](https://boards.straightdope.com/u/dracoi)\ **Post date:** [August 19, 2015, 5:56pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/27 "2015-08-19T17:56:15Z")
> [@ralph124c](#): > > Forget Medicare-what about the 6.5 million people receiving SS, all over 112 years old? > Link:[http://www.newsmax.com/US/ssa-audit-millions-dead/2015/03/10/id/629253/](http://www.newsmax.com/US/ssa-audit-millions-dead/2015/03/10/id/629253/) You might want to read that article before you cite it. Those 6.5 million are not receiving payments. Many of them are in fact \*making \*payments for benefits they will never receive. ---
**Author:** ![ralph124c](https://avatars.discourse-cdn.com/v4/letter/r/8797f3/32.png) [@ralph124c](https://boards.straightdope.com/u/ralph124c)\ **Post date:** [August 19, 2015, 6:52pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/28 "2015-08-19T18:52:46Z")
> [@dracoi](#): > > You might want to read that article before you cite it. Those 6.5 million are not receiving payments. Many of them are in fact \*making \*payments for benefits they will never receive. Maybe, but it is statistically impossible to have that many people alive at ages greater than 112. Poor record keeping? Any life insurance company could figure out that most of these people are frauds. at present, there are only a handful of people alive, over the age of 112. Of course, the SS Administration employs actuaries and statisticians-what do these people do? ---
**Author:** ![Grey](https://avatars.discourse-cdn.com/v4/letter/g/b782af/32.png) [@Grey](https://boards.straightdope.com/u/Grey)\ **Post date:** [August 19, 2015, 7:00pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/29 "2015-08-19T19:00:09Z")
Try to manage the other 66 million living people and the vast array of claims, submissions, counter claims and payouts. ---
**Author:** ![WhyNot](https://avatars.discourse-cdn.com/v4/letter/w/c77e96/32.png) [@WhyNot](https://boards.straightdope.com/u/WhyNot)\ **Post date:** [August 19, 2015, 7:03pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/30 "2015-08-19T19:03:21Z")
And, again, how hard do you want to make life for people who are flagged in error? I’ve got a patient who, at the ripe old age of 85, was informed by the social security administration that she is dead. Made it really hard for Section 8 to pay her rent, or for her to get medical care or her to renew her state ID, or even to pay her phone bill. It took more than three years to straighten that out. You’d think that showing up to the local SSA office while breathing might fix it, but nope. ---
**Author:** ![Grey](https://avatars.discourse-cdn.com/v4/letter/g/b782af/32.png) [@Grey](https://boards.straightdope.com/u/Grey)\ **Post date:** [August 19, 2015, 7:13pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/31 "2015-08-19T19:13:31Z")
Ultimately a lot comes down to complex databases and IT infrastructure needing to be designed. However those type of hidden, pedestrian projects tend to get cut, or shrunk or derided when the large undiscovered linkages showup and drive costs through the roof. ---
**Author:** ![ralph124c](https://avatars.discourse-cdn.com/v4/letter/r/8797f3/32.png) [@ralph124c](https://boards.straightdope.com/u/ralph124c)\ **Post date:** [August 19, 2015, 7:23pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/32 "2015-08-19T19:23:19Z")
> [@WhyNot](#): > > And, again, how hard do you want to make life for people who are flagged in error? I’ve got a patient who, at the ripe old age of 85, was informed by the social security administration that she is dead. Made it really hard for Section 8 to pay her rent, or for her to get medical care or her to renew her state ID, or even to pay her phone bill. It took more than three years to straighten that out. You’d think that showing up to the local SSA office while breathing might fix it, but nope. You don’t see the crime in paying out billions to fraudulently obtained SS number holders? I guess a few hundred billion are nothing to worry about. I see a big problem with this. ---
**Author:** ![davidm](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/davidm/32/225_2.png) [@davidm](https://boards.straightdope.com/u/davidm)\ **Post date:** [August 19, 2015, 7:30pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/33 "2015-08-19T19:30:05Z")
> [@dracoi](#): > > You might want to read that article before you cite it. Those 6.5 million are not receiving payments. Many of them are in fact \*making \*payments for benefits they will never receive. I think the headline on that article is deliberately misleading. > [@](#): > > Audit: 6.5 Million on Social Security Are Over 112 Years Old But what can you expect from Newsmax? ---
**Author:** ![davidm](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/davidm/32/225_2.png) [@davidm](https://boards.straightdope.com/u/davidm)\ **Post date:** [August 19, 2015, 7:43pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/34 "2015-08-19T19:43:45Z")
In anything in the real world, government or private, there is going to be some level of fraud. The question is what is the cost of preventing that fraud? There is a point of diminishing returns, where the cost of catching fraud is higher than the cost of the fraud. Beyond that, there’s the problem of being so diligent that you end up denying legitimate claims. What level of incorrect denials is acceptable? And what is the financial cost of handling appeals? If we want 0% fraud and that is our only goal then the easiest and cheapest solution is to not have a program to begin with. However, we’ve decided as a nation that the humane and decent thing to do is to provide for the medical care of older Americans. If we want to do that then some level of fraud is inevitable. I don’t like it. You don’t like it. Nobody likes it. But there it is. And keep in mind that the same cost benefit considerations regarding fraud also apply to private insurers, only they have more incentive to err on the side of denying legitimate claims. ---
**Author:** ![davidm](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/davidm/32/225_2.png) [@davidm](https://boards.straightdope.com/u/davidm)\ **Post date:** [August 19, 2015, 7:46pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/35 "2015-08-19T19:46:44Z")
> [@ralph124c](#): > > You don’t see the crime in paying out billions to fraudulently obtained SS number holders? I guess a few hundred billion are nothing to worry about. I see a big problem with this. Where do you get the few hundred billion estimate from? ---
**Author:** ![WhyNot](https://avatars.discourse-cdn.com/v4/letter/w/c77e96/32.png) [@WhyNot](https://boards.straightdope.com/u/WhyNot)\ **Post date:** [August 19, 2015, 7:48pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/36 "2015-08-19T19:48:51Z")
> [@ralph124c](#): > > You don’t see the crime in paying out billions to fraudulently obtained SS number holders? I guess a few hundred billion are nothing to worry about. I see a big problem with this. I didn’t say that. I said that one must consider the side effects of reforms, and those side effects include the impact on those identified incorrectly. If we’re going to start putting words into each other’s mouths, I’ll wonder why you want little old ladies to starve to death without medical care or housing. Did you already forget to re-read your cite? “a few hundred billion” isn’t mentioned anywhere in it. Plus, your cite is about people fraudulently paying \*in \*to social security, which I can’t say is high on my list of concerns. ---
**Author:** ![Claverhouse](https://avatars.discourse-cdn.com/v4/letter/c/13edae/32.png) [@Claverhouse](https://boards.straightdope.com/u/Claverhouse)\ **Post date:** [August 19, 2015, 7:54pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/37 "2015-08-19T19:54:16Z")
> [@ralph124c](#): > > Forget Medicare-what about the 6.5 million people receiving SS, all over 112 years old? > Link:[http://www.newsmax.com/US/ssa-audit-millions-dead/2015/03/10/id/629253/](http://www.newsmax.com/US/ssa-audit-millions-dead/2015/03/10/id/629253/) Medicare suddenly got busier. ---
**Author:** ![Hilarity\_N.Suze](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/hilarity_n.suze/32/6223_2.png) [@Hilarity\_N.Suze](https://boards.straightdope.com/u/Hilarity_N.Suze)\ **Post date:** [August 19, 2015, 8:03pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/38 "2015-08-19T20:03:52Z")
I used to work with medical legal professionals. One of them told me the hardest part of the job was convincing their clients (doctors and MHOs) that certain actions they were contemplating were in fact medicare fraud. Because a lot of things that look like they make perfect sense from all points of view (such as doctors going in together to buy some piece of expensive medical equipment to use on their patients) are in fact Medicare fraud. Books on health care law, including Medicare, took up many feet of their bookshelves. With ACA, they would have needed a bigger bookcase, except now it’s all electronic. Of course there are a lot of people intentionally committing large-scale Medicare fraud, but they know they’re doing it and how to cover their tracks, being that they’re organized crime. ---
**Author:** ![Wesley\_Clark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wesley_clark/32/20581_2.png) [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)\ **Post date:** [August 19, 2015, 8:11pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/39 "2015-08-19T20:11:57Z")
> [@BobLibDem](#): > > Let’s cut the real fat- let Medicare negotiate prescription drug prices with the manufacturers. Medicare fraud costs up to $60 billion a year, by comparison allowing Medicare d to negotiate drug prices would only save $16 billion a year. Fraud is the bigger expense. I thought the aca had provisions to fight fraud, but I don’t know the details. ---
**Author:** ![davidm](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/davidm/32/225_2.png) [@davidm](https://boards.straightdope.com/u/davidm)\ **Post date:** [August 19, 2015, 8:13pm UTC](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187/40 "2015-08-19T20:13:48Z")
> [@Hilarity\_N.Suze](#): > > I used to work with medical legal professionals. One of them told me the hardest part of the job was convincing their clients (doctors and MHOs) that certain actions they were contemplating were in fact medicare fraud. Because a lot of things that look like they make perfect sense from all points of view (such as doctors going in together to buy some piece of expensive medical equipment to use on their patients) are in fact Medicare fraud. > > Books on health care law, including Medicare, took up many feet of their bookshelves. With ACA, they would have needed a bigger bookcase, except now it’s all electronic. > > Of course there are a lot of people intentionally committing large-scale Medicare fraud, but they know they’re doing it and how to cover their tracks, being that they’re organized crime. Can you give a short explanation of why doctors going together to buy medical equipment is fraud? I don’t disbelieve you. I’m genuinely curious. I suspect it’s because if doctor’s own some expensive piece of equipment then they have a financial incentive to prescribe the use of that equipment where if the equipment is owned by some third party (a hospital, for example) then they have no incentive to falsely prescribe it’s use. Am I correct? [Previous page](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187.md?page=1) [Next page](https://boards.straightdope.com/t/medicare-fraud-why-isnt-it-a-high-profile-issue/728187.md?page=3)