The largest population of people in the history of our country are turning 65 and becoming Medicare beneficiaries. We fondly refer to this population as the Baby Boomers. They are people born between 1946 and 1964. Unfortunately we are also at an all-time high for Medicare Fraud—the numbers are in the billions. Significantly reducing this fraud could result in lowering the cost of Medicare, so what can we do about it?
As a professional biller and coder I have had the honor of being a part of the business of medicine; a noble career that keeps the money flowing to the providers to bring quality care to patients. It is also our ethical responsibility to report suspicious behavior and potential Medicare fraud. If we see something, we say something.
The Centers for Medicare and Medicaid Services (CMS) partners with various entities and law enforcement agencies to detect and prevent fraud. The Office of Inspector General (OIG) was established to eliminate fraud and abuse. HIPAA, legislation pushed the OIG into a new era, guaranteeing funds for programs. It is the OIG that investigates fraud (confidentially) and will prosecute. If found guilty, these criminals will return the money to the Medicare program, pay civil penalties and may even go to jail.
If you suspect Medicare fraud you can report it online to the Office of the Inspector General or by calling 800-HHS-TIPS. The Qui Tam Provision allows a citizen to bring civil action on behalf of the government. This makes you a protected whistleblower. Also under this provision the whistleblower can awarded a share of the recovery! Your help is needed and you may be compensated.
The Stark Law is known as Physician Self-Referral Law.1 It prohibits the referral of a patient for services, if the referring physician has a financial gain. For example, a physician cannot write a prescription for a wheelchair, and then sell you the wheelchair. Also paying for referrals is crime. The Anti-Kickback Statute prohibits arrangements to induce the purchase of items or services payable by Medicare and Medicaid. Penalties up to $50,000 per kickback plus three times the amount of the claim can be imposed.2 There are Safe Harbors in place to protect business arrangements that are not in violation of this law and some discounting is legal as long as it is at “arms-length”.
Please know that fraud is intentional. It is knowingly and willingly submitting a false claim. A false claim could be for a service that was not provided, or the use of a billing code that would result in a higher reimbursement than the actual service provided. This is most likely to happen in our senior citizen population thus our Medicare beneficiaries. Criminals prey on this population and are draining much needed Medicare funds. It is up to us to do whatever we can to make a difference and report fraud when we suspect it. If you see something, say something.