Are you aware of this? It's outragious

[Wiseacre]

Wanna save nearly a trillion bucks over the next 10 years? Here ya go. Why we aren't working on ways to reduce this is beyond me.


Entitlement Bandits - Michael F. Cannon - National Review Online

" Consider some of the fraud schemes discovered in recent years. In Brooklyn, a dentist billed taxpayers for nearly 1,000 procedures in a single day. A Houston doctor with a criminal record took her Medicare billings from zero to $11.6 million in one year; federal agents shut down her clinic but did not charge her with a crime. A high-school dropout, armed with only a laptop computer, submitted more than 140,000 bogus Medicare claims, collecting $105 million. A health plan settled a Medicaid-fraud case in Florida for $138 million. The giant hospital chain Columbia/HCA paid $1.7 billion in fines and pled guilty to more than a dozen felonies related to bribing doctors to help it tap Medicare funds and exaggerating the amount of care delivered to Medicare patients. In New York, Medicaid spending on the human-growth hormone Serostim leapt from $7 million to $50 million in 2001; but it turned out that drug traffickers were getting the drug prescribed as a treatment for AIDS wasting syndrome, then selling it to bodybuilders. And a study of ten states uncovered $27 million in Medicare payments to dead patients.
These anecdotes barely scratch the surface. Judging by official estimates, Medicare and Medicaid lose at least $87 billion per year to fraudulent and otherwise improper payments, and about 10.5 percent of Medicare spending and 8.4 percent of Medicaid spending was improper in 2009. Fraud experts say the official numbers are too low. “Loss rates due to fraud and abuse could be 10 percent, or 20 percent, or even 30 percent in some segments,” explained Malcolm Sparrow, a mathematician, Harvard professor, and former police inspector, in congressional testimony. “The overpayment-rate studies the government has relied on . . . have been sadly lacking in rigor, and have therefore produced comfortingly low and quite misleading estimates.” In 2005, the New York Times reported that “James Mehmet, who retired in 2001 as chief state investigator of Medicaid fraud and abuse in New York City, said he and his colleagues believed that at least 10 percent of state Medicaid dollars were spent on fraudulent claims, while 20 or 30 percent more were siphoned off by what they termed abuse, meaning unnecessary spending that might not be criminal.” And even these experts ignore other, perfectly legal ways of exploiting Medicare and Medicaid, such as when a senior hides and otherwise adjusts his finances so as to appear eligible for Medicaid, or when a state abuses the fact that the federal government matches state Medicaid outlays. "

 

[uscitizen]

As I have been saying all medicare fraud cases should automatically have a 200% of the fraudlent billing as a fine in addition to any prison time, etc.
This would prevent this from just being a cost of doing business. ie fined 100k for 1 million in fraudlent billing.

 

[daveman]

But we have been repeatedly assured that government-run healthcare will save lots of money.

 

[uscitizen]

We are also assured that private busineses will regulate themselves.

 

[GWV5903]

We are also assured that private busineses will regulate themselves.

Our gov is supposed to referee, instead they offer their services for a price, I'll take my chances with the private sector, under this premise I have a choice....

 

[daveman]

We are also assured that private busineses will regulate themselves.

The same people who assured me that government-run healthcare will save money also assure me that unless the government keeps a microscope on every facet of every industry, businesses will pollute the air and water until all their customers are dead in order to maximize profits.

 

[Stashman]

Wanna save nearly a trillion bucks over the next 10 years? Here ya go. Why we aren't working on ways to reduce this is beyond me.


Entitlement Bandits - Michael F. Cannon - National Review Online

" Consider some of the fraud schemes discovered in recent years. In Brooklyn, a dentist billed taxpayers for nearly 1,000 procedures in a single day. A Houston doctor with a criminal record took her Medicare billings from zero to $11.6 million in one year; federal agents shut down her clinic but did not charge her with a crime. A high-school dropout, armed with only a laptop computer, submitted more than 140,000 bogus Medicare claims, collecting $105 million. A health plan settled a Medicaid-fraud case in Florida for $138 million. The giant hospital chain Columbia/HCA paid $1.7 billion in fines and pled guilty to more than a dozen felonies related to bribing doctors to help it tap Medicare funds and exaggerating the amount of care delivered to Medicare patients. In New York, Medicaid spending on the human-growth hormone Serostim leapt from $7 million to $50 million in 2001; but it turned out that drug traffickers were getting the drug prescribed as a treatment for AIDS wasting syndrome, then selling it to bodybuilders. And a study of ten states uncovered $27 million in Medicare payments to dead patients.
These anecdotes barely scratch the surface. Judging by official estimates, Medicare and Medicaid lose at least $87 billion per year to fraudulent and otherwise improper payments, and about 10.5 percent of Medicare spending and 8.4 percent of Medicaid spending was improper in 2009. Fraud experts say the official numbers are too low. “Loss rates due to fraud and abuse could be 10 percent, or 20 percent, or even 30 percent in some segments,” explained Malcolm Sparrow, a mathematician, Harvard professor, and former police inspector, in congressional testimony. “The overpayment-rate studies the government has relied on . . . have been sadly lacking in rigor, and have therefore produced comfortingly low and quite misleading estimates.” In 2005, the New York Times reported that “James Mehmet, who retired in 2001 as chief state investigator of Medicaid fraud and abuse in New York City, said he and his colleagues believed that at least 10 percent of state Medicaid dollars were spent on fraudulent claims, while 20 or 30 percent more were siphoned off by what they termed abuse, meaning unnecessary spending that might not be criminal.” And even these experts ignore other, perfectly legal ways of exploiting Medicare and Medicaid, such as when a senior hides and otherwise adjusts his finances so as to appear eligible for Medicaid, or when a state abuses the fact that the federal government matches state Medicaid outlays. "

It's about time that someone has finally brought this topic up. The finger usually points to fraudulent disability claims by individuals who are drawing a monthly check, but the stats show that is a small number indeed compared fraud by Doctors, hospitals, big pharma, etc...

An example is how my dad received a power wheel chair through Medicare and it cost $5000.00 dollars. I called the company that makes these chairs and inquired how much it would cost if I walked in with cash and the answer was $1,100. I was in the hospital last yr for hernia surgery, and while looking over the bill I noticed that two Tylenol given to me while there cost me $44.00.

This is outrageous and needs to stop.

 

[SofiaY]

nice..interesting topic to discuss

 

[Greenbeard]

Wanna save nearly a trillion bucks over the next 10 years? Here ya go. Why we aren't working on ways to reduce this is beyond me.

Fraud and abuse are a serious problem. But 1) CMS does go after fraud, and 2) they're currently in the middle of a significant realignment of the way they do so. There was a Congressional Research Service report released a few days ago that details how they go after fraud, as well as what the new ways to go after fraud will look like.

Namely, they're attempting to transition from pay and chase to fighting fraud before a claim is paid. From that report:

Pay and Chase

The need to pay a large number of claims quickly, sets up what has been described as a pay and chase dynamic. Once Medicare claims are paid, they are subject to additional reviews that are not possible during the 30-day requirement to process clean claims. The additional reviews verify accuracy of information (for the provider/supplier and beneficiary), appropriateness, medical necessity, and other characteristics. Under the pay and chase approach, unscrupulous individuals could enroll as Medicare providers/suppliers, receive payments, and CMS subsequently would detect, or chase, overpayments or fraudulent bills to seek recoveries. Fraudulent providers/ suppliers often bill large sums quickly, then disappear, but even for legitimate providers that have received an overpayment in error, it is expensive to identify and recover improper payments. Program integrity emphasis is shifting away from the pay and chase to an approach that attempts to prevent overpayments in the first place.

Part of the way they're doing it is through tools made available in legislation passed last year:

The Patient Protection and Affordable Care Act (PPACA, P.L. 111-148, as amended by P.L. 111- 152) provided CMS with a number of additional program integrity tools, such as enhanced provider/supplier screening requirements, pre-payment claims review for high-risk areas, additional DMEPOS and home health agency surety bond requirements, and new requirements for providers who order certain Medicare services. PPACA also required CMS contractors to track and report performance statistics, such as overpayments identified, fraud referrals, and return on investment. Similarly, PPACA requires the Secretary to evaluate program integrity contractors at least every three years. Further, PPACA required the RAC program to be expanded to Medicare Parts C and D (and Medicaid).

PPACA also requires better data sharing between program integrity entities to monitor and assess potential risks. CMS intends to expand an Integrated Data Repository (IDR) to include claims and payment data from other federal programs such as the Department of Veterans Affairs, the Department of Defense, the Social Security Administration, and the Indian Health Service. CMS expects that the new PPACA authorities will help CMS to migrate more quickly from a pay and chase approach to a deterrent approach.

As shown in Table 8, PPACA increased appropriations for HCFAC [Health Care Fraud and Abuse Control] by a total of $350 million over the period FY2011-FY2020. Specifically, PPACA Sec. 6402 increased HCFAC funding by appropriating from the Medicare Part A Trust Fund $10 million for each FY2010-FY2020. In addition, PPACA Sec. 1128J (as amended by Sec. 1303 of P.L. 111-152) further increased HCFAC funding by appropriating $250 million to the HCFAC program.

I also thought this announcement from CMS in June was pretty interesting:

NEW TECHNOLOGY TO HELP FIGHT MEDICARE FRAUD

Technology is Similar to Tools Used by Credit Card Companies, Builds on White House Campaign to Cut Waste

On the heels of the White House launch of the Campaign to Cut Waste - an administration wide initiative to crack down on waste, fraud and abuse, the Centers for Medicare & Medicaid Services (CMS) announced today that starting July 1, it will begin using innovative predictive modeling technology to fight Medicare fraud. Similar to technology used by credit card companies, predictive modeling helps identify potentially fraudulent Medicare claims on a nationwide basis, and help stop fraudulent claims before they are paid. This initiative builds on the new anti-fraud tools and resources provided by the Affordable Care Act that are helping move CMS beyond its former “pay & chase” recovery operations to an approach that focuses on preventing fraud and abuse before payment is made. [...]

Original Medicare claims will be analyzed using innovative risk scoring technology that applies effective predictive models, an approach similar to that used by the private sector to successfully identify fraud. For the first time, CMS will have the ability to use real-time data to spot suspect claims and providers and take action to stop fraudulent payments before they are paid.

Northrop Grumman, a global provider of advanced information solutions, has been selected through a competitive procurement to develop CMS’ national predictive model technology format using best practices of both public and private stakeholders. Northrop Grumman has partnered with National Government Services (NGS) and Federal Network Systems, LLC, a Verizon company (FNS), to leverage the wealth of claims data and its information to fight health care fraud. CMS used industry guidance, innovative ideas from private and provider entities and related data in developing the scope of work for this national fraud prevention program. Given the importance of this contract to CMS’ overall anti-fraud efforts, this contract is being implemented nationally and ahead of schedule. [...]

Northrop Grumman, through the use of proven predictive models and other advanced analytics, will move rapidly to implement the new technology. Northrop Grumman will deploy algorithms and an analytical process that looks at CMS claims – by beneficiary, provider, service origin or other patterns — to identify potential problems and assign an “alert” and assign “risk scores” for those claims. These problem alerts will be further reviewed to allow CMS to both prioritize claims for additional review and assess the need for investigative or other enforcement actions.

Again, part of the transition away from pay and chase and toward spotting fraud before CMS pays the claim.

 

[The Rabbi]

IOW they are trying to do this like private insurance companies do. This is why the stat that Medicare is more efficient than private companies is bunk. Private companies spend money weeding out fraud before it happens. Thus their overhead is higher. Medicare allows fraud and then attempts to go after it. Much like closing the barn door after the horse is gone, it isn't effective.

Yes, we were assured that gov't healthcare would be cheaper and more efficient. If you think it's expensive now, wait until it's free.

 

[auditor0007]

Wanna save nearly a trillion bucks over the next 10 years? Here ya go. Why we aren't working on ways to reduce this is beyond me.


Entitlement Bandits - Michael F. Cannon - National Review Online

" Consider some of the fraud schemes discovered in recent years. In Brooklyn, a dentist billed taxpayers for nearly 1,000 procedures in a single day. A Houston doctor with a criminal record took her Medicare billings from zero to $11.6 million in one year; federal agents shut down her clinic but did not charge her with a crime. A high-school dropout, armed with only a laptop computer, submitted more than 140,000 bogus Medicare claims, collecting $105 million. A health plan settled a Medicaid-fraud case in Florida for $138 million. The giant hospital chain Columbia/HCA paid $1.7 billion in fines and pled guilty to more than a dozen felonies related to bribing doctors to help it tap Medicare funds and exaggerating the amount of care delivered to Medicare patients. In New York, Medicaid spending on the human-growth hormone Serostim leapt from $7 million to $50 million in 2001; but it turned out that drug traffickers were getting the drug prescribed as a treatment for AIDS wasting syndrome, then selling it to bodybuilders. And a study of ten states uncovered $27 million in Medicare payments to dead patients.
These anecdotes barely scratch the surface. Judging by official estimates, Medicare and Medicaid lose at least $87 billion per year to fraudulent and otherwise improper payments, and about 10.5 percent of Medicare spending and 8.4 percent of Medicaid spending was improper in 2009. Fraud experts say the official numbers are too low. “Loss rates due to fraud and abuse could be 10 percent, or 20 percent, or even 30 percent in some segments,” explained Malcolm Sparrow, a mathematician, Harvard professor, and former police inspector, in congressional testimony. “The overpayment-rate studies the government has relied on . . . have been sadly lacking in rigor, and have therefore produced comfortingly low and quite misleading estimates.” In 2005, the New York Times reported that “James Mehmet, who retired in 2001 as chief state investigator of Medicaid fraud and abuse in New York City, said he and his colleagues believed that at least 10 percent of state Medicaid dollars were spent on fraudulent claims, while 20 or 30 percent more were siphoned off by what they termed abuse, meaning unnecessary spending that might not be criminal.” And even these experts ignore other, perfectly legal ways of exploiting Medicare and Medicaid, such as when a senior hides and otherwise adjusts his finances so as to appear eligible for Medicaid, or when a state abuses the fact that the federal government matches state Medicaid outlays. "

They don't have this problem in China. The punishment for defrauding the government is death. It's simple and effective.

 

[editec]

Oh my GOD, FRUAD is BAD?

Who knew?!

 

[Greenbeard]

Private companies spend money weeding out fraud before it happens. Thus their overhead is higher. Medicare allows fraud and then attempts to go after it.

You think the overhead is lower for pay and chase than deterrence?

 

[konradv]

But we have been repeatedly assured that government-run healthcare will save lots of money.

But we're also told not to touch Medicare by both sides. Are the TPers going to man-up and touch the third rail?

 

[peach174]

It's proof one again that Dem's don't have any clue of how businesses are run.
The Health Secretary issues free preventative health care to women for birth control, breast feeding ,diabetes screening, domestic violence,at the cost to health insurance.
While Diane Fienstein is talking to the committee on the health care bill, that Insurance Companies must cap their rise in premiums.
This free health care for women will cost billions of dollars. How are insurance companies going to be able to afford this without the rise in premiums.
It's going to shut down many insurance companies, because they can't afford this expense without them being able to pass on the cost to insurer's.
The worst is yet to come when Seniors will not be able to find Dr,s to treat them, because they can not afford the extremely low payments that Medicare is paying.
You think the cost of health care is bad now, wait till Seniors have to go to the Emergency rooms because they can't find any Doctors.
They complained about 30 million or so going to emergency rooms as the rise in heath costs, wait till 76million Senors have to start doing it.
This Health Care Bill must be repealed.

 

[Iridescence]

We are also assured that private busineses will regulate themselves.

The same people who assured me that government-run healthcare will save money also assure me that unless the government keeps a microscope on every facet of every industry, businesses will pollute the air and water until all their customers are dead in order to maximize profits.

intricacies.... bazaar unmapped labyrinths meant to ultimately weed out the wheat from the tares... eh, and then to serve higher unmentionable purposes...

 

[The Rabbi]

Private companies spend money weeding out fraud before it happens. Thus their overhead is higher. Medicare allows fraud and then attempts to go after it.

You think the overhead is lower for pay and chase than deterrence?

You have some proof to the contrary?

 

[bill5]

It's about time that someone has finally brought this topic up. The finger usually points to fraudulent disability claims by individuals who are drawing a monthly check, but the stats show that is a small number indeed compared fraud by Doctors, hospitals, big pharma, etc...

An example is how my dad received a power wheel chair through Medicare and it cost $5000.00 dollars. I called the company that makes these chairs and inquired how much it would cost if I walked in with cash and the answer was $1,100. I was in the hospital last yr for hernia surgery, and while looking over the bill I noticed that two Tylenol given to me while there cost me $44.00.

This is outrageous and needs to stop.

Good luck w/that.

This is standard procedure between "wellness centers" (hospitals etc) and the insurance companies. Prices vary widely and they routinely try to gouge insurance companies, who then negotiate them down to a price both agree on as if they were 2 hagglers at some flea market. Revolting and absurd are far too kind to describe it. There are not even set prices for procedures, never mind the fraud of doing ones that aren't needed or the extreme cases of billing for things never provided.

I don't agree with the gov't taking over everything to say the least, but healthcare DOES, unfortunately, need to be much MUCH more tightly regulated and audited. A CT scan is a standard thing; it should cost X dollars (or at least have a ceiling), perhaps allowing for MINOR tweak like "cost of living" in the given area, etc. No organization should be allowed to charge whatever they want for things like this.

 

[daveman]

But we have been repeatedly assured that government-run healthcare will save lots of money.

But we're also told not to touch Medicare by both sides. Are the TPers going to man-up and touch the third rail?

Are the fear-mongering Democrats going to continue to claim the GOP wants to push grandma over a cliff for even mentioning reform?

 

[uscitizen]

Wanna save nearly a trillion bucks over the next 10 years? Here ya go. Why we aren't working on ways to reduce this is beyond me.


Entitlement Bandits - Michael F. Cannon - National Review Online

" Consider some of the fraud schemes discovered in recent years. In Brooklyn, a dentist billed taxpayers for nearly 1,000 procedures in a single day. A Houston doctor with a criminal record took her Medicare billings from zero to $11.6 million in one year; federal agents shut down her clinic but did not charge her with a crime. A high-school dropout, armed with only a laptop computer, submitted more than 140,000 bogus Medicare claims, collecting $105 million. A health plan settled a Medicaid-fraud case in Florida for $138 million. The giant hospital chain Columbia/HCA paid $1.7 billion in fines and pled guilty to more than a dozen felonies related to bribing doctors to help it tap Medicare funds and exaggerating the amount of care delivered to Medicare patients. In New York, Medicaid spending on the human-growth hormone Serostim leapt from $7 million to $50 million in 2001; but it turned out that drug traffickers were getting the drug prescribed as a treatment for AIDS wasting syndrome, then selling it to bodybuilders. And a study of ten states uncovered $27 million in Medicare payments to dead patients.
These anecdotes barely scratch the surface. Judging by official estimates, Medicare and Medicaid lose at least $87 billion per year to fraudulent and otherwise improper payments, and about 10.5 percent of Medicare spending and 8.4 percent of Medicaid spending was improper in 2009. Fraud experts say the official numbers are too low. “Loss rates due to fraud and abuse could be 10 percent, or 20 percent, or even 30 percent in some segments,” explained Malcolm Sparrow, a mathematician, Harvard professor, and former police inspector, in congressional testimony. “The overpayment-rate studies the government has relied on . . . have been sadly lacking in rigor, and have therefore produced comfortingly low and quite misleading estimates.” In 2005, the New York Times reported that “James Mehmet, who retired in 2001 as chief state investigator of Medicaid fraud and abuse in New York City, said he and his colleagues believed that at least 10 percent of state Medicaid dollars were spent on fraudulent claims, while 20 or 30 percent more were siphoned off by what they termed abuse, meaning unnecessary spending that might not be criminal.” And even these experts ignore other, perfectly legal ways of exploiting Medicare and Medicaid, such as when a senior hides and otherwise adjusts his finances so as to appear eligible for Medicaid, or when a state abuses the fact that the federal government matches state Medicaid outlays. "

They don't have this problem in China. The punishment for defrauding the government is death. It's simple and effective.

sounds good to me.