Keeping an Eye Out for Medical Fraud

The federal government is losing billions of dollars each year because of Medicare fraud, reports Forbes magazine. Ultimately this costs the taxpayers.

The federal government is losing billions of dollars each year because of Medicare fraud, reports Forbes magazine. Ultimately this costs the taxpayers. In an attempt to stop what adds up to between $60 and $90 billion per year of loss from fraudulent schemes, the government is analyzing trends as well as suspicious medical professionals. But the help of the individual beneficiaries might be exactly what is needed to crack down on fraud.

Becoming familiar with the types of schemes in practice might help patients catch these medical crooks. Whether the therapist, pharmacist or physician, there are plenty of individuals and services for Medicare beneficiaries to keep an eye on.

Scheming at Skilled Nursing Facilities

There are a couple of frauds that take advantage of Medicare part A. One focuses on skilled nursing facilities where patients receive therapy and rehabilitation after debilitating illness or stroke. Medicare beneficiaries who qualify will often stay at a nursing facility after their extended hospital stay.

Unfortunately, however, fraudulent facilities may try something called “upcoding.” This form of billing fraud distorts the actual services rendered by adding procedure codes which were unnecessary and not actually performed during the patient’s stay. A similar scheme bills the government for excessive therapy or podiatry foot care that is not only unnecessary but may even harm the patient.

Home Health Care Fraud

In an attempt to protect patients and the government, Medicare beneficiaries who are “home bound” must receive a physician’s certification for services performed in the home such as:

•Physical therapy

•Occupational therapy

•Speech language therapy

•Skilled nursing care

Some doctors will use this as an opportunity to falsely certify that, for instance, an insulin-dependent diabetic patient cannot inject herself and must have a nurse come to perform her insulin injections. The charge for the nurse will be processed.

Another scheme involves asking the beneficiary to sign forms that verify a nurse or therapist came to the home when in fact no home care was actually provided. A final measure includes offering the patient cash or free monthly meals and house cleaning in exchange for allowing the physician to fraudulently certify that he or she is home bound.

Problems with Prescription Drugs

Individuals who receive the part D prescription drug benefit should also take care when filling their medication needs. Prescription shorting is one form of fraud in which a scheming pharmacy regularly fills prescriptions a few pills short, hoping the beneficiary will not notice while Medicare is billed the full amount.

A similar plan asks the patient to take half their prescription at the beginning of the month and come back again for the rest of their month’s drug supply. Meanwhile, the pharmacy bills Medicare for both times for the entire amount.

An even more involved tactic is to motivate the beneficiary to seek a narcotic prescription from the physician which is then billed to Medicare. But the patient receives cash, and the drugs are simply cycled back to the pharmacy or, worse, sold illegally on the street.

Smart Ways for Patients to Be Protected

For Medicare patients, there are multiple precautions to take in protecting yourself from fraud, error or abuse. Always keep your Medicare, Medicaid and Social Security numbers hidden and do not give them out to strangers, especially if they are offering a service or selling something.

A good tip to remember, says the government Medicare fraud website, is that “Medicare does not call or visit to sell you anything.” And Medicare.gov adds, “remember that nothing is ever ‘free.’ Don’t accept offers of money or gifts for free financial service.”

When it comes to record keeping, it is advisable for individuals to keep documentation of their doctors visits, tests and any procedures in a private personal health care journal or calendar. You can add the Medicare Summary Notices and Part D Explanation of Benefits to this file. 

Check your bill when leaving the pharmacy to ensure that you have the correct medication and the right amount. Also double check your medical bills so that you are not given duplicate charges, services not ordered by your doctor or a fee for something you never received. Be certain that you are not seeking or being encouraged to claim services that you do not really need.

A good general rule is to remain cautious and aware. And if you are having trouble understanding a document, call or other notice, do not hesitate to ask someone you trust to help clarify and explain. Using Medicare effectively and ethically requires attention to detail and thoroughness.

(medical fraud / shutterstock)