PERSONAL SAFETY Watching out for Medicaid fraud

Watching out for Medicare fraud, even in a pandemic

STAY SAFE

Steve Rose is a retired Sandy Springs Police captain, veteran Fulton County police officer and freelance writer. He is the author the book “Why Do My Mystic Journeys Always Lead to the Waffle House?” and the column “View from a Cop.”

I was on the phone recently with my brother, debating as usual who was the favorite son. He is in Houston; I’m here, as is my mother. He informed me that he called her first on Mother’s Day and so he wins. I told him I took her to lunch at a nice Italian restaurant and paid $85 on the tab, so “checkmate,” my friend.

Having defeated my nemesis, the discussion moved onto the topic of fraud in the healthcare world. My brother is retired from law enforcement and now contracts to investigate Medicare fraud, which he says keeps him very busy. Apparently, business is good. Medicare is a government health insurance program, so obviously, it is mammoth in size, volume heavy, and ripe for fraud.

A major concern is not specifically focused on patient fraud, but fraud committed by medical providers. Medicare fraud investigators find themselves diving into a sea of paperwork to expose frauds such as double billing, phantom billing (which is billing for services or supplies the patient never received), sending multiple bills for the same service, and what they call “upcoding” (billing for a more expensive service than the patient actually received).

He told me a lot of focus is on doctors who are short on ethics, who engage in these types of frauds strictly for profit—and they make a lot of money doing it.

COVID-19 opened up a brand-new page on the topic of fraud. In April of this year, the Department of Justice indicted 21 defendants across the U.S. for taking part in various healthcare related fraud that exploited the COVID-19 pandemic. The DOJ said false billing to federal programs and theft from federally funded pandemic assistance programs amounted to $149 million. The department seized over $8 million in cash and other fraud proceeds.

When the pandemic first hit in 2020, fraudsters wasted no time. By the end of the year, the FBI was looking into fraud schemes involving vaccines, antibody testing, the procurement of PPE (personal protective equipment,) other COVID-19 equipment, and fraudulent treatments.

Medicare fraud isn’t limited to COVID claims, of course. In May, a federal judge sentenced 10 defendants for their roles in a health care fraud scheme involving three physical therapy clinics that recruited and paid kickbacks to beneficiaries of Blue Cross Blue Shield health benefit programs who submitted false claims for services the clinics never provided or were not medically necessary. The defendants included the owner of the clinics, sentenced to 120 months prison, and over $4.1 million in restitution, a doctor, sentenced to 57 months and $2.8 million, two co-owners, a therapy assistant and three “patient recruiters.” (Source: DOJ, Southern District of Florida)

A Pennsylvania man was sentenced to 20 years in prison, fined $40,000 and ordered to pay nearly $4 million in restitution for running a prescription “pill mill” from his medical practice in

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Philadelphia. The defendant was convicted of fraudulently billing insurers for medically unnecessary physical therapy, acupuncture, chiropractic adjustments, and prescription drugs, as well as treatments that were never administered. He provided his patients with a “goody bag” of addictive narcotics including muscle relaxers, anti-inflammatories, and Schedule IV controlled substances for pain. and then submitted pharmacy claims through his company, netting more than $4,000 for each bag. He prescribed oxycodone to “pill-seeking” patients in exchange for their tacit approval that he would submit excessive claims to the patient’s insurer for the “goody bag” and unnecessary services. The DOJ estimates he profited an estimate $4 million from 2015 to 2018. (Source: DOJ, Eastern District of Pennsylvania)

Fraud committed by patients and others include bogus marketing, convincing people to provide insurance ID numbers and other personal information to bill for non-rendered services, or simply to steal their identity. Identity swapping and impersonating a healthcare professional are two common frauds that someone like you and I may run into.

Remember to treat your insurance card and Medicare information as you would a credit card. Never loan or even allow another to access the ID number.

If you are contacted, either by phone or email, by someone identifying himself or herself as a doctor or nurse practitioner, for the purpose of soliciting services, make sure that you confirm who she or he is by requesting specific information on the company. Online profiles are available for most doctors and clinic services. Don’t make quick decisions before you check them out.

Here is your off-topic tip: If you have old prescription drugs you no longer use, several police agencies have DEA drop boxes available. Check your local department for locations.

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