When suppliers and physicians overbill Medicare.
Studies estimate that medicare fraud, waste and abuse seep through America’s medical bills, ranging annually from 3 to 10 percent of total health care spending, or $93 billion to $310 billion.
One of the medicare schemes used is to offer consumers something “free”, who can resist free, because “their insurance will cover it”. While it is true that the insured senior is not directly paying for it, what many seniors and family members do not realize is that the “free” service or product is costing American taxpayers billions of dollars annually. The bottom-line is that the patient gets something “free” and the taxpayers pay for it.
Scammers know medicare rules better than most people. They know that insurers have to pay the claims within 30 days, which means that a careful scrutiny won’t happen until the money is already out the door.
Medicare reimbursement rules vary depending on the services provided. For example, for genetic testing a doctor has to determine that the test is medically necessary. In the case of genetic tests to determine a hereditary risk of certain types of breast cancer are covered. So are tests that identify genes that can predispose someone to certain blood clots and the risk of embolisms.
While the definition of “medically necessary” can be confusing and what is medically necessary in my mind may not be medically necessary in your mind, other areas medicare rules are more direct. In the case of home medical care, Medicare will pay only for homebound patients rehabilitating after a hospital stay. Hospice care is available only for patients where a doctor has determined they have less than six months to live. Medical equipment like power wheelchairs and knee braces require a physician’s order.
The problem is that seniors are often approached by firms offering all of these services, at no cost to them, if they’ll simply provide their Medicare cards. Once again, who can resist “free”. Also, like many areas of our government Medicare has been hacked. Already this year, hackers broke into the claims files of the insurers Anthem, Inc., and Premera Blue Cross, compromising medical identities of more than 90 million people, including more than 50,000 employees and dependents insured with AT&T.
To address the challenges of providing medical services to the senior members of our community, in 2010, Congress approved $100 million in funding to give the Centers for Medicare and Medicaid Services predictive analytics software. These computer programs identify suspicious claims and patterns so the government can check them out before paying. In 2014, the software was credited with halting fraudulent payments worth $210.7 million. Other steps step implemented are to stop printing Social Security numbers on Medicare cards and to require home health agencies to post a $50,000 surety bond before they can do business with Medicare. While these steps are helping, it is believed that the benefits derived is small.