A few months ago, Medicare fraud was one of the topics discussed on CBS’s 60 Minutes. It was stated that the government may have lost sixty billion dollars to fraudulent activities within the Medicare system.
The fraud scheme as presented by the show 60 Minutes reported that various people or their agents were submitting fraudulent bills for medically unnecessary treatments or treatments that were never actually performed. These criminals were able to collect claims easily because the government did not have the ability to verify the validity of a claim before making payments that had to be paid within thirty days.
I have always wondered how people could defraud the government of the United States for 60 billion dollars with relative ease over time. The most powerful nation in the world has become a sucker to organized crime who operates across the US with impunity.
In the healthcare IT news, there was an article on October 15, 2010 stating, “IT Aid to Largest Medicare Fraud in History.” The article started by stating that information Technology and data mining capabilities had a role in dismantling what authorities are calling the largest Medicare fraud scheme ever, involving seventy-three members and associates of organized crime and more than 163 million dollars in fraudulent billing. The organized crime enterprise was charged October 13th, 2010 in five judicial districts in unsealed indictments.
It was described that these criminals allegedly stole the identities of doctors and thousands of Medicare beneficiaries and operated at least 118 phony clinics in twenty-five states.
This bust was made possible with the collaborative efforts of various govrnment organizations through investments in modern technology. This new technology has the ability to compare in a matter of days, analysis of electronic evidence that previously took months to analyze using traditional investigative tools. It also improves data and information sharing between the Center for Medicare and Medicaid Services (CMS) and law enforcement to identify patterns that lead to fraud. This interagency effort is known as the Fraud Prevention and Enforcement Action Team (HEAT). It is tasked with combating Medicare fraud by building upon and strengthening existing programs combating fraud, as well as investing in new resources and technology to prevent waste and abuse.
What I may not understand is why it took the loss of about 50 billion dollars to alert the government. There were series of providers and Medicare beneficiaries who, for years, have complained to the government items that showed on their statements were phony and yet no one within the agency took their complaints seriously. It will have taken a very small fraction of that stolen 50 billion dollars to develop an IT system that would have put these criminals in check long ago. This is definitely another case against the bureaucratic process.
