Medicare fraud: Why isn't it a high-profile issue?

[Grey]

@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.

You did note the SSN of these dead 112 year olds are being used, and consequently taxed, by illegal immigrants?

[davidm]

I have to say that it seems like it would be simple enough to flag the SS numbers of people who are beyond retirement age and are paying in but not collecting.

[dracoi]

@ralph124c

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?

But the “fraud” in this cause is often illegal immigration or identity theft. The SSA is not a division of the INS and is not tasked with enforcing immigration. The SSA is not a division of the FBI, and is not tasked with enforcing banking laws.

[Ionizer]

@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.

I know of a couple Docs (mostly Orthos, one being my employer at the time) that formed a separate LLC or such and opened an MRI Imaging Center. A very high percentage of their patients were ‘referred’ to this one particular Imaging place even when conservative treatment was the most obvious way to go (wait and see, so to speak). Often, the MRI was done prior to ever seeing the patient, just an ‘open-order’ for any shhoulder pain or such. A few patients wanted to go elsewhere (closed to their home, etc) and were told that if they did not use this one Imaging Center, they would not be seen by the Doc. Period. The Doc(s) swore up and down there was no law against such, and it disgusted me to see so may minimal-type injuries getting multiple exams ordered upon them for no real reason other than profit-driven motives.

I do recall hearing my employer screaming to office-mgr about having to ‘pay-off’ (settle pre-court), so to speak, one particular patient who threatened to take him to court about this requirement. The teen-aged patient’s Dad was an attorney and he found it ridiculous that, since they lived in Wichita Falls, TX, that they had to to come back to OKC to get what was a routine exam (post-office-visit) and could not be proven to be of superior quality to what Doc could provide at his privately-owned Center. The yelling stopped suddenly when Doc realized that us workers were still there, and I have no idea if there was any payout to patient, but Doc knew it was sketchy at a minimum, no doubt at all. I do know I made copies of her X-rays and sent them to patient to be used by another Ortho, fwiw.

It does exist, IME, and a lot more often than a person may think if they dig deep enough into a lot of imaging centers/business. Legal or not, IANAL.

[adaher]

@dracoi

But the “fraud” in this cause is often illegal immigration or identity theft. The SSA is not a division of the INS and is not tasked with enforcing immigration. The SSA is not a division of the FBI, and is not tasked with enforcing banking laws.

Doesn’t matter. If the fraud has to do with SS numbers, it’s in the SSA’s jurisdiction. SSA can’t deport anyone, but they can refer criminals to the FBI for arrest.

[Voyager]

@ralph124c

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?

If you want them to check up on people, you might ask those asshole in Congress to stop cutting their headcount.
They are sure wasteful - administration costs are 0.39%. If they had overhead anywhere like the insurance companies, they can check up a lot more, Of course running down all these fake SSNs would cost a lot. Are these people getting benefits or just paying for benefits unused?

[voltaire]

@Velocity

…conservatives, because they tend to decry fraud and waste.
[

…except when they tend to [URL=“http://www.politifact.com/florida/statements/2014/mar/03/florida-democratic-party/rick-scott-rick-scott-oversaw-largest-medicare-fra/”]defraud and cry waste.](http://www.medicarenewsgroup.com/news/medicare-faqs/individual-faq?faqId=6a130489-e387-476d-a358-c77cfba68367)

[robert_columbia]

@Algher

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.

I’m also seeing something like this. Traditionally, fraud, to exist, requires that there be an intentional, knowing deception that actually deceives the victim into believing something that is not true and that also causes them to give up property that they would not have given up had they known the real truth.

What I’m seeing in this thread, however, are TPS report cover sheet type problems - in other words, procedural violations that are obvious on their face and do not deceive anyone. The solution to a “you forgot to put X on the top of the sheet” problem isn’t a fraud prosecution, but a stern visit from a Medicare official saying, “All the doctors now are putting X on top of the sheet now. Didn’t you get the memo? If you could start putting X on top of the sheet, that would be greeaaat.”

@WhyNot

…
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)…

Wait, isn’t the question of whether a patient is or is not homebound a clinical judgment? If a doctor honestly believes that their patient is homebound but Medicare disagrees, wouldn’t that be a case of Medicare trying to practice medicine and provide their own second opinion?

[robert_columbia]

@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…

Which essentially means that it’s not fraud, at least not traditional, legal fraud, which can only be committed knowingly and intentionally. A mistaken act can lead to civil liability and a requirement to reimburse improperly paid fees, but isn’t criminal fraud.

@davidm

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?

Presumably, the real problem is not buying the equipment per se, but in being able to charge patients equipment usage or rental fees for its use. If the equipment is just a piece of equipment that the doctors sometimes use when the feel it would be helpful but still charge the same amount, I’m not seeing that as anywhere close to fraud, unless the machine is biased or something, or there is a requirement for a second opinion that is being bypassed or something like that.

[WhyNot]

@robert_columbia

Wait, isn’t the question of whether a patient is or is not homebound a clinical judgment? If a doctor honestly believes that their patient is homebound but Medicare disagrees, wouldn’t that be a case of Medicare trying to practice medicine and provide their own second opinion?

Yes. Sometimes the doctor is, in fact, a lying weasel, though. One of the doctors our agency got a lot of referrals from just went to jail for fraudulently certifying patients as homebound. The reason I’m not in jail with him is that I refused to certify those patients (as the nurse) and didn’t open those cases and we reported him.

That’s how it should work. There should be agreement between the nurse and the doctor both that, by clinical guidelines, the patient is homebound. If we can’t agree, then the one who doesn’t agree refuses the case. It doesn’t always work that way in reality. Sometimes the nurses are under pressure from their bosses to open cases, because we’ve got to pay the bills.

I don’t play that game, which has gotten me in some tense conversations with my boss. But “the doctor said so” is not a defense, legally or ethically. When Dr. ______ went down along with a dozen other staff members from various agencies, I did get a thank you, at last.

[GrumpyBunny]

@Ionizer

I know of a couple Docs (mostly Orthos, one being my employer at the time) that formed a separate LLC or such and opened an MRI Imaging Center. A very high percentage of their patients were ‘referred’ to this one particular Imaging place even when conservative treatment was the most obvious way to go (wait and see, so to speak).

This is extremely common across specialties. When docs go in on a piece of equipment, they’re much, much, much more likely to refer the patient for a procedure using that piece of equipment, even if a cheaper or more appropriate procedure exists.

[robert_columbia]

@WhyNot

Yes. Sometimes the doctor is, in fact, a lying weasel, though. One of the doctors our agency got a lot of referrals from just went to jail for fraudulently certifying patients as homebound. The reason I’m not in jail with him is that I refused to certify those patients (as the nurse) and didn’t open those cases and we reported him.

That’s how it should work. There should be agreement between the nurse and the doctor both that, by clinical guidelines, the patient is homebound…

Ah. So what I suppose is the case is that there are obvious cases, such as where the patient is out running marathons, where even the most dimwitted individual with an advanced degree in hyperbolic topology is expected to recognize that the patient can’t possibly be considered homebound under any rational argument whatsoever. There are other cases, however, (such as where a patient theoretically has the strength and dexterity to roll out of bed, knock the door open with a broomhandle, and crawl across the street) where homebound-ness (or lack thereof) really is a clinical judgment and two professionals could essentially be both right according to their own interpretation of the situation.

Am I on track with that one, or is homebound-ness a stark, objective measurement (e.g. via weightlifting scores where any score under X means conclusively homebound and X or above means conclusively not homebound) that isn’t subject to clinical judgment?

[ralph124c]

@Voyager

If you want them to check up on people, you might ask those asshole in Congress to stop cutting their headcount.
They are sure wasteful - administration costs are 0.39%. If they had overhead anywhere like the insurance companies, they can check up a lot more, Of course running down all these fake SSNs would cost a lot. Are these people getting benefits or just paying for benefits unused?

What is so hard about filtering a SS database, and throwing out numbers that show ages > 112? Or is this too much for poor, over worked SSA?

[Grey]

I love that you think there’s only one database. That’s precious.

[Voyager]

@ralph124c

What is so hard about filtering a SS database, and throwing out numbers that show ages > 112? Or is this too much for poor, over worked SSA?

And when you do - what? First you need to see how many of these people have the wrong age because of data entry errors. Second, are they getting checks (unlikely) or are they paying? Third you need to send agents to find them and check it out. If they lied about their number they probably lied about their address also. Then, even if they found someone, what do they do? SS employees are not INS agents.
It is an awful lot of work to stop them from paying money into the system that they won’t ever get back.

[Voyager]

@Grey

I love that you think there’s only one database. That’s precious.

I assume that within SSA finding ages is not too hard. They know mine. But sharing data across agencies? From what I’ve seen of government computer systems, that would get interesting.

[WhyNot]

@robert_columbia

Ah. So what I suppose is the case is that there are obvious cases, such as where the patient is out running marathons, where even the most dimwitted individual with an advanced degree in hyperbolic topology is expected to recognize that the patient can’t possibly be considered homebound under any rational argument whatsoever. There are other cases, however, (such as where a patient theoretically has the strength and dexterity to roll out of bed, knock the door open with a broomhandle, and crawl across the street) where homebound-ness (or lack thereof) really is a clinical judgment and two professionals could essentially be both right according to their own interpretation of the situation.

Am I on track with that one, or is homebound-ness a stark, objective measurement (e.g. via weightlifting scores where any score under X means conclusively homebound and X or above means conclusively not homebound) that isn’t subject to clinical judgment?

Homebound status, as defined by Medicare, is both taxingly specific and frustrating vague.

an individual shall be considered “confined to the home” (homebound) if the following two criteria are met:

Criteria One

The patient must either:

Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence or
Have a condition such that leaving his or her home is medically contraindicated.
If the patient meets one of the Criteria-One conditions, then the patient must also meet two additional requirements defined in Criteria-Two below.

Criteria-Two:

There must exist a normal inability to leave home and leaving home must require a considerable and taxing effort.

So you don’t have to go out never, but it must be difficult for you to go out, and that difficulty must be due to a documented medical condition. You can go out for medical care, to get your hair cut, to go to church, attend a birthday party, etc. But if you’re going out, a) it’s hard b) because of a medical condition and c) you don’t do it often and d) when you do, it isn’t for long.

Notice that things like “considerable” and “effort” and “infrequent” and “short duration” are not objectively described. That’s where the professional, clinical judgement comes in.